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Stripping Mature Women


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Even though the fertility transition in the West Bank and Gaza Strip is well under way, it is clear that the classical theory of the demographic transition alone cannot explain the ongoing high demand for children in the modern yet conflicting context of the Palestinian territories. Individual-level variables have always been the main focus of studies on Palestinian fertility. However, the role of contextual variables is of central importance to best capture the mechanisms of fertility change in the region. To better understand the fertility behaviour of Palestinian women over time, we use the most recent retrospective data available from the Demographic and Health survey conducted by the Palestinian Central Bureau of Statistics in 2004 by modeling a multilevel discrete-time logistic regression on the birth histories of ever-married women aged 15-49 at the time of the survey. Regional characteristics representing the proportion of Jewish settlers, the status of women, and infant mortality are the three main contextual dimensions considered in this study. We argue that the status of women, especially through higher education, is the main factor behind the decline of Palestinian fertility, especially among older women. The decline in infant mortality only has a slightly negative impact on fertility. Finally, the presence of Jewish settlers contributes to decrease Palestinian fertility as regions with a higher proportion of settlers had a significantly lower fertility.


"I will be forever heartbroken by the treatment of these inspiring and courageous women from the Philippines, India, Nigeria, Russia, Uganda, Bangladesh, Syria etc at the hands of the U.A.E. 'Justice System'."


All operations were performed by gynecologic oncologist-leading comprehensive surgery team including colorectal surgeons, urologic surgeons, thoracic surgeons and hepatobiliary surgeons (23). Standard cytoreductive procedures included hysterectomy, oophorectomy, low anterior resection, lymphadenectomy, and omentectomy. EUAS is defined as splenectomy, distal pancreatectomy, cholecystectomy, liver resection, diaphragm stripping and/or resection, and partial gastrectomy. Records of residual mass were retrieved for all patients and optimal cytoreduction was defined as a residual tumor size


Standard surgery for ovarian cancer was performed on all patients enrolled in the present study. EUAS procedures were applied to all patients whenever it was necessary to debulk the tumor optimally. The list of EUAS procedures and the operative outcomes for each cohort are listed in Table 2. The most commonly performed EUAS procedure was splenectomy (43.8%). The second most common procedure was diaphragm stripping and/or resection (23.4%). Overall, 77 patients, including 16 elderly patients, received EUAS. The proportion of patients who received EUAS was not different between the two groups (58.1% vs. 50.0%, P=0.420). The proportion of patients who received multiple EUAS procedures was similar between the two groups (19.1% vs. 25.0%, P=0.465). The median estimated blood loss for the entire groups was 850 mL. The estimated blood loss and intraoperative transfusion rate were statistically similar between the two groups. The optimal debulking rate (residual mass


Intraoperative injuries and post-operative morbidities within 30 days were described in Table 3. The most common intraoperative injury associated with EUAS was diaphragm perforation, resulting from aggressive diaphragmatic tumor debulking or diaphragmatic full thickness resection. The most common medical morbidity was infection. Pleural effusion and pneumothorax were the most common morbidities which possibly resulted from EUAS. We also observed that these complications are more frequent in elderly patients, but without statistical significance (6.7% vs. 18.8%, P=0.077). A total of 77 of 153 women received one or more EUAS procedures during their surgery. Among these patients, complications and morbidities were compared according to age (Table 4). Overall, the complications and morbidities were not significantly different. However, pleural effusion and pneumothorax were significantly more common in the elderly group (8.2% vs. 31.3%, P=0.028). Among the 5 elderly patients who received upper abdominal procedures and experienced postoperative pleural effusions or pneumothorax, five patients had resection and/or stripping of the diaphragm and three patients had splenectomy. None of the patients had malignant effusions before surgery. Among the five patients, one patient developed a pneumothorax during resection of the diaphragm; the patient recovered well with conservative care, including tube drainage. Four patients had postoperative pleural effusions which were successfully managed with tube drainage. In one of the four patients, pneumonia was developed. Despite intensive care, she died of infection after 51 postoperative days.


In the recent study demonstrating that EUAS can help increase the optimal cytoreduction rate, Chi et al. (17) included patients up to 88 yr of age and reported a 76% of optimal cytoreduction rate. Recently, Wright et al. (10) reported the surgical outcome of 46 elderly women, including 33 cases with advanced disease. In the study, they reported that 2% of elderly patients had a splenectomy and the optimal cytoreduction rate for the elderly group (including 22% of early stage patients) was 81%. Recently, Sharma et al. (12) reported an 89.6% optimal debulking rate involving 77 elderly patients, including 26% early stage patients. They defined 'supraradical' surgical procedures as splenectomy, and/or diaphragm resection, and/or liver resection, and/or combined small and large bowel resection, and/or exenteration. In the study, 15 elderly patients (19.4%) underwent 'supraradical' procedures. In our study, we applied EUAS to 16 of 32 elderly patients (50.0%). Our optimal debulking rate (87.5%) was similar to the previous study. However, it should be noted we included only patients with advanced disease, while the previous studies included 22-26% patients of early stage ovarian cancers. As Bristow et al. (24) demonstrated in their meta-analysis, our data also showed that a high optimal debulking rate can be translated into an improved OS (median survival 57.8 months) in elderly patients with advanced ovarian cancer.


In terms of surgical complication, our data suggest that there is no difference between young patients and fit, elderly patients in general. This corresponds with the results of previous studies (10, 12, 13). However, our data raised a concern that the incorporation of upper abdominal procedures may increase the frequency of specific complications and may cause more physical burden to the elderly patients who underwent EUAS procedures. First, we observed that pleural effusions and pneumothorax were more likely to develop in elderly patients who underwent EUAS procedures. Post-operative pleural effusions are relatively common complications in patients who undergo diaphragm resection and/or stripping (25-27). Previous reports emphasize that most of the cases can be managed without respiratory compromise or further complications. Also, in the report by Eisenhauer et al. (26), the age of the patients who had effusions after diaphragm peritonectomy was not different from that of patients that did not undergo diaphragm peritonectomy. Therefore, at the present time, it is not clear that diaphragmatic surgery is the cause of more frequent post-operative pleural effusion in the elderly. However, given that elderly patients are more vulnerable to respiratory complications, such as pneumonia or respiratory distress, we recommend that intensive care should be given to the elderly patients, especially when they received diaphragm surgery and/or a splenectomy. Second, we found that elderly patients who received multiple EUAS had increased blood loss, longer operating time, and more frequent intraoperative transfusions. Since all of these factors can deteriorate the postoperative outcomes of elderly patients, unnecessary upper abdominal procedures should be minimized. 041b061a72


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