Hospitalization costs associated with leiomyoma

Inpatient Pediatric Tonsillectomy: Does Hospital Type Affect Cost and Outcomes of Care?

OBJECTIVE

To ascertain whether hospital type is associated with differences in total cost and outcomes for inpatient tonsillectomy.

STUDY DESIGN

Cross-sectional analysis of the 2006, 2009, and 2012 Kids' Inpatient Database (KID).

SUBJECTS AND METHODS

Children ≤18 years of age undergoing tonsillectomy with/without adenoidectomy were included. Risk-adjusted generalized linear models assessed for differences in hospital cost and length of stay (LOS) among children managed by (1) non-children's teaching hospitals (NCTHs), (2) children's teaching hospitals (CTHs), and (3) nonteaching hospitals (NTHs). Risk-adjusted logistic regression compared the odds of major perioperative complications (hemorrhage, respiratory failure, death). Models accounted for clustering of patients within hospitals, were weighted to provide national estimates, and controlled for comorbidities.

RESULTS

The 25,685 tonsillectomies recorded in the KID yielded a national estimate of 40,591 inpatient tonsillectomies performed in 2006, 2009, and 2012. The CTHs had significantly higher risk-adjusted total cost and LOS per tonsillectomy compared with NCTHs and NTHs ($9423.34/2.8 days, $6250.78/2.11 days, and $5905.10/2.08 days, respectively; P < .001). The CTHs had higher odds of complications compared with NCTHs (odds ratio [OR], 1.48; 95% CI, 1.15-1.91; P = .002) but not when compared with NTHs (OR, 1.19; 95% CI, 0.89-1.59; P = .23). The CTHs were significantly more likely to care for patients with comorbidities (P < .001).

CONCLUSION

Significant differences in costs, outcomes, and patient factors exist for inpatient tonsillectomy based on hospital type. Although reasons for these differences are not discernable using isolated claims data, findings provide a foundation to further evaluate patient, institutional, and system-level factors that may reduce cost of care and improve value for inpatient tonsillectomy.

Healthcare utilization and costs among women diagnosed with uterine fibroids: a longitudinal evaluation for 5 years pre- and post-diagnosis

OBJECTIVE

To evaluate the healthcare utilization, treatments, and costs incurred by women with uterine fibroids (UF), compared to those without UF, for 5 years before and 5 years after diagnosis.

RESEARCH DESIGN AND METHODS

This is a longitudinal, retrospective case-control study. A total of 84,954 women with a diagnosis of UF, along with matched controls of women without UF, were selected from the Truven Health MarketScan claims database (2000-2010). The date of diagnosis of the UF patient was assigned as the index date for both the UF patient and her matched control.

MAIN OUTCOME MEASURES

Healthcare resource utilization, treatments, and costs (in 2010 USD) were evaluated annually for the 5 year periods before and after the index date.

RESULTS

UF patients had more outpatient and emergency room visits than controls before diagnosis, and more inpatient, outpatient, and emergency room visits than controls after diagnosis. Annual total healthcare costs were significantly higher for patients than controls during the last 3 years pre-index and all 5 years post-index. Overall, the difference was $12,623 over 10 years, with a difference of $1435 in the 5 years pre-diagnosis and a difference of $11,188 in the 5 years post-diagnosis. The cost difference between UF patients and controls was highest in the first year post-diagnosis, reaching $6131, and the difference was even larger when comparing clinically symptomatic UF patients to controls. The use of medications and surgical procedures related to UF peaked in the year post-diagnosis, with 39% of patients receiving a surgical treatment within the year.

KEY LIMITATIONS

UF patients included in the study did not include undiagnosed and potentially asymptomatic UF patients; the impact of disease severity on the costs of UF patients was not evaluated.

CONCLUSIONS

Patients with UF incurred significantly higher healthcare utilization and costs than those without UF, both pre- and post-diagnosis.

MED12 and HMGA2 mutations: two independent genetic events in uterine leiomyoma and leiomyosarcoma

Recent identification of somatic MED12 mutations in most uterine leiomyomas brings a new venue for the study of the tumorigenesis of leiomyomas. We are particularly interested in the correlation of MED12 and HMGA2 gene products in leiomyomas and leiomyosarcomas with and without MED12 mutations. To address these issues, in this study we examined MED12 mutations in a large cohort of usual type leiomyomas (178 cases) and uterine leiomyosarcomas (32 cases). We found that 74.7% (133/178) of leiomyomas had MED12 mutations, which was consistent with several independent studies. In contrast, only 9.7% (3/32) of leiomyosarcomas harbored MED12 mutations. Expression analysis by western blot and immunohistochemistry revealed that those leiomyomas with complex MED12 mutations had significantly lower protein products than the matched myometrium. Interestingly, most leiomyosarcomas without MED12 mutations also had very low levels of MED12 expression in comparison to the matched myometrium. These findings suggest a potential functional role of MED12 in both benign and malignant uterine smooth muscle tumors. When we further examined HMGA2 expression in all leiomyomas and leiomyosarcomas, we found that HMGA2 overexpression was exclusively present in those leiomyomas with no MED12 mutation, accounting for 10.1% (18/178) of total leiomyomas and 40% (18/45) of non-MED12 mutant leiomyomas. Twenty-five percent (8/32) of leiomyosarcomas had HMGA2 overexpression, and no MED12 mutations were found in HMGA2 positive leiomyosarcoma. These findings strongly suggest that MED12 mutations and HMGA2 overexpression are independent genetic events that occur in leiomyomas, and they may act differently in the tumorigenesis of uterine leiomyomas.

Myomectomy during Caesarean Birth in Fibroid-Endemic, Low-Resource Settings

If myomectomy during caesarean delivery becomes a widespread practice, it could potentially eliminate multiple surgeries for both indications. However, many surgeons have been reluctant to adopt this policy without conclusive evidence demonstrating its safety. This study reviews the publications on caesarean myomectomy especially from the African Continent with respect to duration of surgery, blood loss, length of hospital stay, and blood transfusions. Judging from the lack of large studies on caesarean myomectomy, the proportion of surgeons who attempt the procedure is largely low because of concerns about its safety. However, most of the authors suggested that the complications and morbidity following caesarean myomectomy do not significantly differ from those occurring during caesarean section alone, while fertility is apparently not compromised by this treatment. With careful patient selection, adequate experience, and efficient haemostatic measures, the procedure does not appear as hazardous as was once thought. This piece of information is relevant for counseling women who request for the simultaneous removal of previously diagnosed fibroids during caesarean section. Staff and facilities for safe management of haemorrhage are a requisite for the procedure. Large randomized trials are needed to guide decisions as to the best clinical practice regarding myomectomy during caesarean delivery.

The burden of uterine fibroids for African-American women: results of a national survey

BACKGROUND

Uterine fibroids have a disproportionate impact on African-American women. There are, however, no data to compare racial differences in symptoms, quality of life, effect on employment, and information-seeking behavior for this disease.

METHODS

An online survey was conducted by Harris Interactive between December 1, 2011 and January 16, 2012. Participants were U.S. women aged 29-59 with symptomatic uterine fibroids. African-American women were oversampled to allow statistical comparison of this high-risk group. Bivariate comparison of continuous and categorical measures was based on the t-test and the Chi-squared test, respectively. Multivariable adjustment of risk ratios was based on log binomial regression.

RESULTS

The survey was completed by 268 African-American and 573 white women. There were no differences between groups in education, employment status, or overall health status. African-American women were significantly more likely to have severe or very severe symptoms, including heavy or prolonged menses (RR=1.51, 95% CI 1.05-2.18) and anemia (RR=2.73, 95% CI 1.47-5.09). They also more often reported that fibroids interfered with physical activities (RR=1.67, 95% CI 1.20-2.32) and relationships (RR=2.27, 95% CI 1.23-4.22) and were more likely to miss days from work (RR=1.77, 95% CI 1.20-2.61). African-American women were more likely to consult friends and family (36 vs. 22%, P=0.004) and health brochures (32 vs. 18%, P<0.001) for health information. Concerns for future fertility (RR=2.65, 95% CI 1.93-3.63) and pregnancy (RR=2.89, 95% CI 2.11-3.97) following fibroid treatments were key concerns for black women.

CONCLUSIONS

African-American women have more severe symptoms, unique concerns, and different information-seeking behavior for fibroids.

Clinical 24 month experience of the first MRgFUS unit for treatment of uterine fibroids in Australia

AIM

To describe and evaluate treatment of uterine fibroids using Magnetic Resonance Guided Focused Ultrasound (MRgFUS) during its first 24 months of use at The Royal Women's Hospital Melbourne.

METHODS

One hundred Victorian women were treated with MRgFUS using the ExAblate 2000 system. Treatment outcomes based on fibroid volume shrinkage measured at 4 and 12 months post-treatment and symptom severity score assessment (Symptom Severity Score Quality of Life - SSS-QOL) pre- and post- (4-6 weeks, 4, 6 and 12 months) treatment.

RESULTS

Mean non-perfused volume of the treated fibroids were 67% ± 25% (n = 100) immediately post-treatment. At 4 months post-treatment, the treated fibroids demonstrated an average volume reduction of 29% ± 32% (n = 74) and at 12 months 38% ± 45% (n = 32). Mean symptom severity scores (SSS-QOL) improved by 51% from 59 ± 21 (n = 97) at baseline to 29 ± 17 (n = 36) by 12 months.

CONCLUSION

From our experience, we believe there is a role for MRgFUS in the treatment of uterine fibroids in selected women.

MR-guided high-intensity focused ultrasound treatment for symptomatic uterine leiomyomata: long-term outcomes

RATIONALE AND OBJECTIVES

To evaluate the long-term clinical outcomes of magnetic resonance--guided high-intensity focused ultrasound (MR-g HIFU) treatments for symptomatic uterine leiomyomata.

MATERIALS AND METHODS

Patients were recruited for a prospective study for MR-g HIFU treatments of symptomatic leiomyomata, with up to 3-year follow-up. The study was approved by the institutional review board and was Health Insurance Portability and Accountability Act--compliant. Clinical assessments were obtained at 3 months, 6 months, and 1, 2, and 3 years after MR-g HIFU, as well as uterine fibroid symptom severity scores (SSS) and health-related quality of life questionnaires (UFS-QOL). MR imaging was performed at each follow-up to assess the efficacy of the treatment at 6 months, 1 year, 2 years, and 3 years.

RESULTS

Fifty-one leiomyomata in 40 patients were treated. All patients were treated within the US Food and Drug Administration guidelines with leiomyomata localized on MR and treated with sonication. The mean baseline volume of treated leiomyomata was 336.9 cm(3). The mean improvement scores for transformed SSS was 47.8 (P < .001) and for tUFS-QOL was 39.8 (P < .001) at 3 years. The mean volume decrease in treated leiomyomata was 32.0% (P < .001), and, in the uterus, the volume decrease was 27.7% (P < .001) at 3 years. There were no long-term complications.

CONCLUSIONS

Long-term follow-up data from MR-g HIFU treatments show sustained symptomatic relief among enrolled patients. Although the results are preliminary, MR-g HIFU for the treatment of uterine leiomyomata may result in acceptable long-term outcomes at 3 years.

Dollars and sense of interval appendectomy in children: a cost analysis

PURPOSE

Although initial nonoperative management of focal, perforated appendicitis in children is increasingly practiced, the need for subsequent interval appendectomy remains debated. We hypothesized that cost comparison would favor continued nonoperative management over routine interval appendectomy.

METHODS

Decision tree analysis was used to compare continued nonoperative management with routine interval appendectomy after initial success with nonoperative management of perforated appendicitis. Outcome probabilities were obtained from literature review and cost estimates from the Kid's Inpatient Database. Sensitivity analyses were performed on the 2 most influential variables in the model, the probability of successful nonoperative management and the costs associated with successful observation. Monte Carlo simulation was performed using the range of cost estimates.

RESULTS

Costs for continued nonoperative observation were estimated at $3080.78 as compared to $5034.58 for the interval appendectomy. Sensitivity analysis confirms a cost savings for nonoperative management as long as the likelihood of successful observation exceeds 60%. As the cost of nonoperative management increased, the required probability for its success also increased. Using wide distributions for both probability estimates as well as costs, Monte Carlo simulation favored continued observation in 75% of scenarios.

CONCLUSION

Continued nonoperative management has a cost advantage over routine interval appendectomy after initial success with conservative management in children with focal, perforated appendicitis.

Modeling the impact of comorbidity on breast cancer patient outcomes

The objective of this paper is to model the impact of comorbidity on breast cancer patient outcomes (e.g., length of stay and disposition). Previous studies suggest that comorbidities may significantly affect mortality risks for breast cancer patients. The 2006 AHRQ Nationwide Inpatient Sample (NIS) is used to analyze the relationships among comorbidities (e.g., hypertension, diabetes, obesity, and mental disorder), total charges, length of stay, and patient disposition as a function of age and race. A multifaceted approach is used to quantify these relationships. A causal study is performed to explore the effect of various comorbidities on patient outcomes. Least squares regression models are developed to evaluate and compare significant factors that influence total charges and length of stay. Logistic regression is used to study the factors that may cause patient mortality or transferring. In addition, different survival models are developed to study the impact of comorbidity on length of stay with censoring information. This study shows the interactions and relationship among various comorbidities and breast cancer. It shows that certain hypertension may not increase length of stay and total charges; diabetes behaves differently among general population and breast cancer patients; mental disorder has an impact on patient disposition that affects true length of stay and charges, and obesity may have limited effect on patient outcomes. Moreover, this study will help to better understand the expenditure patterns for population subgroups with several chronic conditions and to quantify the impact of comorbidities on patient outcomes. Lastly, it also provides insight for breast cancer patients with comorbidities as a function of age and race.

Reproductive characteristics and risk of uterine leiomyomata

OBJECTIVE

To evaluate whether menstrual and reproductive characteristics may influence development of uterine leiomyomata since sex steroid hormones have been hypothesized to play a role in their development.

DESIGN

A prospective cohort study (Nurses' Health Study II).

SETTING

Participants were identified from 14 states and followed for 14 years.

PATIENT(S)

A cohort of 116,609 female registered nurses ages 25-42 at baseline.

INTERVENTION(S)

We obtained data on uterine leiomyomata incidence and exposures through biennial questionnaires. We calculated hazard ratios and 95% confidence intervals adjusted for known and suspected risk factors.

MAIN OUTCOME MEASURE(S)

Uterine leiomyomata confirmed by ultrasound or hysterectomy.

RESULT(S)

During 1,163,439 person-years of follow-up, 9,847 self-reported cases of hysterectomy- or ultrasound-confirmed uterine leiomyomata were reported. We observed a lower incidence of uterine leiomyomata with later age at menarche, longer menstrual cycles, parity, later age at first and last birth, shorter time since last birth, and breastfeeding.

CONCLUSION(S)

Hormonal and anatomical changes associated with menstruation and pregnancy may influence uterine leiomyomata incidence.

What are the total costs of surgical treatment for uterine fibroids?

OBJECTIVE

To investigate the direct and indirect costs of uterine fibroid (UF) surgery.

METHODS

Data were obtained from the MarketScan Commercial Claims and Encounters databases for 1999-2004. Our sample included 22,860 women with insurance coverage who were treated surgically for UF and 14,214 women who were treated nonsurgically for UF. Medical care costs and missed workdays were divided into baseline (1 year prior to surgery) and postoperative (1 year after surgery) periods. For a subsample of women, we calculated average annual costs 3 years before and after their surgery.

RESULTS

Of patients electing surgery, 85.9% underwent hysterectomy, 7.6% myomectomy, 4.9% endometrial ablation, and 1.6% uterine artery embolization (UAE). Women undergoing UAE incurred the highest medical care costs in the operative year ($16,430 unadjusted, $20,634 adjusted for confounders), followed by hysterectomy ($15,180 unadjusted, $17,390 adjusted), myomectomy ($14,726 unadjusted, $18,674 adjusted), and endometrial ablation ($12,096 unadjusted, $13,019 adjusted). Women treated nonsurgically incurred costs of $7,460 unadjusted and $8,257 adjusted during the year after they were diagnosed with UF. Three years after surgery, patients treated with hysterectomy had the lowest annual costs. Missed workdays in the year after surgery were high, resulting in significant losses to employers in the magnitude of $6,670-$25,229, depending on treatment, values assigned to missed workdays, and whether the analyses adjusted for confounders.

CONCLUSIONS

UF surgical treatment costs were high. Absenteeism and disability were important components of the cost burden of UF treatment for women, their employers, and the healthcare system.

The antifibrotic drug halofuginone inhibits proliferation and collagen production by human leiomyoma and myometrial smooth muscle cells

OBJECTIVE

To investigate the effects of the antifibrotic drug halofuginone on extracellular matrix production, cell proliferation, and apoptosis of cultured myometrial and leiomyoma smooth muscle cells.

DESIGN

Comparative and controlled experimental research study.

SETTING

University research laboratory.

PATIENT(S)

Leiomyoma and myometrial tissues were obtained from eight different patients at the time of elective hysterectomy.

MAIN OUTCOME MEASURE(S)

The effects of halofuginone on cell proliferation were assessed by tritiated thymidine uptake assays and cell count assays. Effects on TGFbeta1, collagen type I, and collagen type III mRNA levels were assessed by quantitative real-time polymerase chain reaction. Effects on apoptosis were assayed using a chemiluminescent assay to measure changes in caspase 3 and 7.

RESULT(S)

Halofuginone inhibited cell proliferation of both leiomyoma and autologous myometrial cells in a dose-dependent manner by inhibiting DNA synthesis within 24 hours and later inducing apoptosis (as measured by increased caspase 3/7) by 48-72 hours. Halofuginone also significantly reduced collagen type I (alpha1) and collagen type III (alpha1) mRNA levels, as well as the profibrotic factor TGFbeta1 mRNA levels in both cell types.

CONCLUSION(S)

These results provide evidence to support the use of the antifibrotic drug halofuginone as a novel drug treatment for uterine leiomyomas.

Antiproliferative effects by Let-7 repression of high-mobility group A2 in uterine leiomyoma

High-mobility group A2 (HMGA2) is commonly overexpressed in large leiomyomas. HMGA2 is an important regulator of cell growth, differentiation, apoptosis, and transformation. As a predicted target of Let-7 microRNAs (Let-7s), HMGA2 can be repressed by Let-7s in vitro. MicroRNA profiling analysis revealed that Let-7s were significantly dysregulated in uterine leiomyomas: high in small leiomyomas and lower in large leiomyomas. To evaluate whether Let-7 repression of HMGA2 plays a major role in leiomyomas, we analyzed the molecular relationship of HMGA2 and Let-7s, both in vitro and in vivo. We first characterized that exogenous Let-7 microRNAs could directly repress the dominant transcript of HMGA2, HMGA2a. This repression was also identified for two cryptic HMGA2 transcripts in primary leiomyoma cultures. Second, we found that the endogenous Let-7s were biologically active and played a major role in the regulation of HMGA2. Then, we illustrated that Let-7 repression of HMGA2 inhibited cellular proliferation. Finally, we examined the expression levels of Let-7c and HMGA2 in a large cohort of leiomyomas (n = 120), and we found high levels of Let-7 and low levels of HMGA2 in small leiomyomas, and low levels of Let-7 and high levels of HMGA2 in large leiomyomas. Our findings suggest that the Let-7-mediated repression of HMGA2 mechanism can be an important molecular event in leiomyoma growth.

Benign gynecologic conditions

Benign gynecologic conditions constitute the majority of the general gynecologist's practice. Along with health maintenance examinations, contraceptive management, family planning issues, and concerns about incontinence, the gynecologic conditions for which patients commonly present include adnexal masses, leiomyomata, endometriosis, and pelvic inflammatory disease. This article addresses each of these last four entities and incorporates a discussion of their etiologies, clinical presentations, keys to diagnosis, and the various treatment options available.

Lycopene and other carotenoid intake in relation to risk of uterine leiomyomata

OBJECTIVE

Carotenoids have antioxidant properties and have been associated with reduced risks of some cancers. We hypothesized that carotenoid intake may reduce the risk of diagnosed uterine leiomyoma (UL).

STUDY DESIGN

We evaluated the associations between dietary carotenoids and risk of diagnosed UL in 82,512 premenopausal women aged 26-46 years in 1991 in the Nurses' Health Study II over 10 years of follow-up. Diet was assessed every 4 years with a validated food frequency questionnaire, and incidence of UL was assessed biennially by questionnaire.

RESULTS

Total lycopene intake was not associated with diagnosed UL risk. Intake of beta-carotene was associated with slightly increased risks of diagnosed UL; this association was restricted to current smokers (for highest vs lowest quintile, relative risk = 1.36, 95% confidence interval 1.05 to 1.76; P(trend) = .003).

CONCLUSION

Overall, our findings do not suggest that carotenoids reduce the risk of diagnosed UL. Among current smokers, high intake of beta-carotene may slightly increase risk of diagnosed UL.

Clinical improvement and shrinkage of uterine fibroids after thermal ablation by magnetic resonance-guided focused ultrasound surgery

OBJECTIVE

Hysterectomy or myomectomy are the accepted treatments for symptomatic uterine fibroids. Heat ablation of uterine fibroids has been shown to be an effective alternative treatment. The aim of this study was to determine the clinical efficacy of non-invasive thermal ablation by transcutaneous magnetic resonance-guided high-intensity focused ultrasound (MRgFUS) for the treatment of symptomatic uterine fibroids.

METHODS

In this prospective study, MRgFUS ablation of uterine fibroids was performed in 35 symptomatic women scheduled for hysterectomy. Clinical symptoms, patient satisfaction and uterine size were determined at 1 month and 6 months after the procedure.

RESULTS

This outpatient procedure was very well tolerated by all women. Sixty-nine percent (24/35) of the treated patients reported either significant or partial improvement in symptoms. Treated fibroids decreased in volume by 12% and 15% at 1 and 6 months, respectively. Minor transient side-effects were observed in two women. Six women underwent hysterectomy during the follow-up period.

CONCLUSION

This study demonstrates the clinical efficacy of MRgFUS ablation of uterine fibroids. This novel, non-invasive surgical approach may offer an alternative therapy for women with uterine fibroids.

Health care resource use for uterine fibroid tumors in the United States

OBJECTIVE

The purpose of this study was to quantify the total direct cost to the US health care system for the management of uterine leiomyomas.

STUDY DESIGN

We used Center for Disease Control heath care databases for estimates of inpatient care, ambulatory care, and outpatient care of leiomyomas. With International Classification of Diseases-9 codes for fibroid tumors and fibroid-related conditions, all fibroid-related care was identified in each database. Inpatient and ambulatory surgical cases were stratified by surgical procedure, and outpatient clinical cases were categorized by type of visit and health care provider. With the use of Medicare's RBRVU reimbursement rates for 2000 as a proxy for the cost of physician services and Medicare diagnostic-related group reimbursement as a proxy for facility costs, the total direct cost to the US health care system for the care of fibroid tumors was estimated.

RESULTS

Total direct cost to treat uterine fibroid tumors was estimated at 2,151,484,847 dollars. Most of the cost was due to inpatient care, in particular, hysterectomy.

CONCLUSION

Uterine fibroid tumors consume a significant amount of health care resources in the United States.

The genetic heterogeneity of uterine leiomyomata

Research investigating the genetics of UL has already been successful in gathering epidemiologic evidence for heritability, establishing the clonal and mosaic nature of these tumors, correlating genotypic and phenotypic characteristics, defining cytogenetic subgroups, and identifying specific genes involved in tumorigenesis. Although UL are known to be benign tumors, the impact they have on the lives of so many women can only be described as "malignant". For this reason, continuing the quest to ascertain the genes, functions, and mechanisms integral to UL development is absolutely imperative. Genetic tests for personalized medical management of women with fibroids is at the threshold for providing the most appropriate treatments (Fig. 3), and combined with developing less invasive therapies portends a brighter future for a major health problem for women.

Clinical outcomes of focused ultrasound surgery for the treatment of uterine fibroids

OBJECTIVE

To assess outcomes at 6 and 12 months after magnetic resonance-guided focused ultrasound surgery (MRgFUS) for symptomatic uterine leiomyomas.

DESIGN

Multicenter clinical trial.

SETTING

Academic medical centers.

PATIENT(S)

Premenopausal women with symptomatic uterine leiomyomas and no plans for future pregnancy (n = 109 at 6 months and n = 82 at 12 months).

INTERVENTION(S)

A single treatment session of MRgFUS for uterine fibroids.

MAIN OUTCOME MEASURE(S)

Reduction in fibroid symptoms as measured by the symptom severity score (SSS) of the Uterine Fibroid Quality-of-Life Instrument (UFS-QOL), the only validated measure of leiomyoma symptomatology. A 10-point reduction in the SSS was selected as the targeted improvement.

RESULT(S)

Seventy-one percent of women undergoing MRgFUS reached the targeted symptom reduction at 6 months, and 51% reached this at 12 months. The magnitude of improvement in SSS was greater than predicted, with subjects having a mean decrease of 39% and 36% at 6 and 12 months, respectively. This paralleled the improvement seen using the short form-36 instrument. A modest volume reduction similar in magnitude to the treated volume was seen. The incidence of adverse events was low.

CONCLUSION(S)

MRgFUS treatment results in short-term symptom reduction for women with symptomatic uterine leiomyomas with an excellent safety profile.

Spatial differences in biologic activity of large uterine leiomyomata

OBJECTIVE

To evaluate the growth pattern of the large uterine leiomyomata (ULM), we examined the spatial gene distributions, vessel density, proliferative activity, and hyaline degeneration.

DESIGN

Tissue sections from three-dimensional large ULM, matched myometrium, and small ULM were collected and microarrayed. The spatial difference of the tumor activity was mapped in large ULM.

SETTING

University clinical research laboratory.

PATIENT(S)

Hysterectomy specimens from 7 patients with large (>10 cm) ULM and 3 patients with large (>10 cm) uterine leiomyosarcomas.

INTERVENTION(S)

Tissue microarray analysis by the immunohistochemistry.

MAIN OUTCOME MEASURE(S)

Selected gene products, vessel density, and the percentage of hyaline degeneration were all scored in tissue cores/sections of large and small ULM against matched myometrium.

RESULT(S)

We found that there was a spherical spatial difference of the tumor activities in large ULM. The tumor region next to the periphery, the most biologically active zone, demonstrated higher levels of gene expression, a higher density of vessels, a higher proliferative rate and a lower level of hyaline degeneration. The large ULM have higher levels of gene products (except for estrogen and progesterone receptors) than small ULM.

CONCLUSION(S)

In comparison of the spatial patterns of the gene activity between the large ULM and the large uterine leiomyosarcoma, the large ULM illustrate a growth pattern of nutritional dependence.

The Economic Impact of Uterine Fibroids in the United States: A Summary of Published Estimates

OBJECTIVE

To present a summary of published estimates of the economic burden of uterine fibroids in the United States and identify areas for additional research.

METHODS

A search of three electronic databases, MEDLINE, EMBASE, and Current Contents, was conducted, along with a review of information on the Internet and abstraction of economic data.

RESULTS

Only 10 papers and 1 Internet document met our inclusion criteria and were used to abstract data. Cost estimates for surgically invasive treatments of uterine fibroids included hysterectomy (USD 5,012-7,934), myomectomy (USD 5,425-11,839), and uterine artery embolization (UAE) (USD 5,425-7,645) (2004 USD). One cost-effectiveness study estimated lower costs and higher quality-adjusted life years with UAE compared with hysterectomy. A second study estimated potential savings of USD 4.2 million in hospital charges in the United States if higher rates of vaginal (vs. abdominal) hysterectomy would be achieved after pretreatment with gonadotropin hormone-releasing hormone (GnRH) agonists compared to without pretreatment with GnRH agonists (80% vs. 13%). There were no estimates of the total direct and indirect economic burden of uterine fibroids. Neither estimates of the costs for the ambulatory care of fibroids nor studies estimating the indirect costs associated with the management of fibroids and their symptoms were found.

CONCLUSIONS

This summary of published U.S. economic estimates shows that despite the high prevalence of fibroids and their impact on clinical practice and women's lives, there is very little published information on their economic impact apart from data showing standard treatments for uterine fibroids are invasive and expensive. Reduction in the need for and cost of invasive procedures by the increased usage of noninvasive treatments could potentially achieve significant national cost savings, but further clinical and economic studies are needed.

A prospective study of hypertension and risk of uterine leiomyomata

Although uterine leiomyomata (also known as fibroids or myomas) affect the reproductive health and well-being of approximately 25% of premenopausal women, risk factors are poorly understood. Elevated diastolic blood pressure may increase fibroid risk through uterine smooth muscle injury, not unlike atherosclerosis. The authors prospectively examined the relation between diastolic blood pressure and incidence of clinically detected leiomyomata. The sample included 104,233 premenopausal nurses from 14 US states enrolled in the Nurses' Health Study II. Participants, aged 25-42 years, had intact uteri and no history of cancer or fibroids at enrollment in 1989. During the 827,348 woman-years of follow-up (1989-1999), 7,466 incident diagnoses of uterine leiomyomata, confirmed by ultrasound or hysterectomy, were reported. With a multivariable Cox proportional hazards model, the relative risk of self-reported ultrasound- or hysterectomy-confirmed uterine leiomyomata according to diastolic blood pressure in 1989 and time-varying antihypertensive use was estimated. With adjustment for age, race/ethnicity, body mass index, and reproductive history covariates, for every 10-mmHg increase in diastolic blood pressure, the risk of fibroids rose 8% (5-11%) and 10% (7-13%) among nonusers and users of antihypertensive medications, respectively. Elevated blood pressure has an independent, positive association with risk for clinically detected uterine leiomyomata among premenopausal women. Investigating this association may suggest possible pathways to prevent fibroids.

Involvement of fumarate hydratase in nonsyndromic uterine leiomyomas: genetic linkage analysis and FISH studies

Recently, germline mutations of the fumarate hydratase (FH) gene, in 1q42.1, have been found to be involved in syndromes associated with uterine leiomyomas (ULs). Compelling evidence also supports a genetic liability to develop nonsyndromic UL, although susceptibility genes have not been reported to date. Loss of heterozygosity (LOH) studies have found no or rare evidence of LOH of FH in nonsyndromic UL. However, the karyotypes of these tumors were not reported, and cytogenetic aberrations of 1q42-44 have been observed infrequently in UL. To determine whether FH mutations also may predispose women to developing nonsyndromic UL, we performed a genetic linkage study with DNA from 123 families containing at least one affected sister pair. In addition, to assess the frequency of FH loss specifically in UL with 1q rearrangements, we performed a fluorescence in situ hybridization (FISH) analysis of UL with 1q rearrangements. Analysis of the genotyping data revealed evidence suggestive of linkage to the FH region among study participants who were less than 40 years of age at diagnosis (Zlr 1.7 at D1S547, P = 0.04). FISH results showed that one copy of FH was absent in 9 of 11 ULs. These data indicate that loss of FH might be a significant event in the pathogenesis of a subset of nonsyndromic ULs.

HMGA2 expression in uterine leiomyomata and myometrium: quantitative analysis and tissue culture studies

The high mobility group gene, HMGA2, is frequently expressed in uterine leiomyomata (UL) with chromosomal rearrangements of 12q15. In contrast, HMGA2 expression has not been detected in karyotypically normal UL or in myometrium, but has been detected in these tissues after culture. To characterize further the expression pattern of HMGA2, we assessed HMGA2 expression by RT-PCR followed by Southern blot hybridization, and by real-time PCR in three tissue panels: (1) primary myometrial cultures, (2) uncultured tissue from 15 karyotypically normal samples consisting of eleven 46,XX UL and four matched myometrial specimens, and (3) uncultured tissue from ten UL with 12q15 rearrangements and three matched myometrial specimens. HMGA2 expression was detected in all samples from the three panels. The level of HMGA2 expression in karyotypically normal UL was similar to the level of expression in myometrium; however, it was significantly less than the level measured in UL with 12q15 rearrangements. This expression analysis by use of detection methods of different sensitivities underscores the importance of studies of HMGA2 expression in uncultured tissues and of careful interpretation of results from experiments on cultured cells. Moreover, detection of HMGA2 expression in myometrium and in UL without 12q15 rearrangements, tissues previously thought not to express HMGA2, suggests that HMGA2 expression is required in normal adult myometrial physiology.

Focused ultrasound treatment of uterine fibroid tumors: safety and feasibility of a noninvasive thermoablative technique

OBJECTIVE

The purpose of this study was to determine the safety and efficacy of focused ultrasound surgery with magnetic resonance imaging guidance for the noninvasive treatment of uterine leiomyomas.

STUDY DESIGN

Fifty-five women with clinically significant uterine leiomyomas were treated. Pain and complications were assessed prospectively, and posttreatment magnetic resonance imaging was used to measure the treatment effects. Patients in three of the five centers underwent planned hysterectomy after treatment, which provided pathologic correlation of treatment.

RESULTS

Seventy-six percent of the enrolled patients completed the full treatment session. All treatments were conducted in an outpatient setting with minimal discomfort for subjects and no major complications. Pathologic examination of the uterus confirmed that magnetic resonance imaging guidance provides the safe and accurate delivery of effective levels of thermal energy with a 3-fold increase in volume of histologically documented necrosis, compared with treatment volume (6.6 +/- 0.8 vs 18.4 +/- 3.9 mL, P <.005).

CONCLUSION

Magnetic resonance imaging-guided focused ultrasound surgery appears to be a well-tolerated treatment for uterine leiomyomas.