Cosmetic surgery of the neck as an office procedure

A simple office procedure to eliminate permanently double chin deformity and senile neck cords and with nearly invisible scars is described. Postoperative complications are mitigated by the use of autogenous fat grafts and constant aspiration of the wound cavity both during and after surgery. Most patients are able to resume their normal activities in several days.     

Pulmonary function testing and bronchoprovocation--a simplified office procedure

A critique of standardized bronchial provocation procedures is presented in order to make this increasingly important methodology more clinically popular. At the present time when sophisticated technology is taking the patient away from even well trained physicians, this is an attempt to abbreviate a valuable technique for the needs of a busy office practice. Pharmacologic bronchoprovocation with fewer mediator dilutions and the use of a simple spirogram can provide very satisfactory diagnostic information.     

Life after infertility treatment: a long-term investigation of marital and sexual function

After leaving in-vitro fertilization (IVF) treatment, both successful and unsuccessful women are generally lost to follow-up. In order to assess overall life satisfaction as well as marital and sexual adjustment after the completion of infertility treatment, three groups of women were studied: group 1 (n = 41), successful IVF women; group 2 (n = 16), unsuccessful IVF women who adopted; and group 3 (n = 18), unsuccessful IVF women who remained childless. All women who had completed a minimum of three IVF cycles between the years 1982 and 1993 were invited to participate in a 'life after infertility' follow-up study. Those who agreed were mailed a lengthy questionnaire which included questions about their reproductive history and infertility treatment, the impact of infertility on their marital and sexual relationship and their final thoughts about treatment. Four standardized questionnaires were also administered. Results revealed that women who became biological mothers through IVF were significantly more satisfied with their lives than women who were unsuccessful in IVF and remained childless (F = 8.62, P < 0.001). Childless women reported that infertility had exerted a significantly greater negative impact on their marriages than that reported by the other two groups. There were no significant differences, however, between the three groups on the standardized measures of marital and sexual satisfaction.     

The Acridine Orange test: a clinically relevant screening method for sperm quality during infertility investigation?

To determine the clinical usefulness of Acridine Orange (AO) staining of spermatozoa as a screening test for the evaluation of semen quality during basic infertility investigation, semen smears from 103 randomly chosen males of subfertile couples were examined. The median duration of infertility was 4.5 years (range 1-15) and the median age was 33 years (range 21-43). The outcome of AO staining ranged from 5 to 81%, with a median of 24%, green fluorescent spermatozoa. Results were not significantly related to the parameters of semen analysis (sperm count, motility, standard morphology, viability, pH and volume, as well as fructose concentration and number of found cells) or to local sperm antibody testing and semen cultures. Fluorescence after AO staining was also not related to sperm functional capacity (evaluated using sperm-mucus interaction tests in vitro and in vivo), or the medical history of the patient. No significant differences in the AO test outcome were seen in patients with explained and unexplained infertility, or with regard to subsequent fertility [with a median value of 21% (range 5-46) green fluorescence in the fertile group, compared with a median value of 28% (range 9-81) green fluorescence in the other men]. The results of this prospective study indicate that under the usual conditions of conception, the AO test is not clinically useful as a screening procedure to determine semen quality during basic infertility investigation.     

Intrauterine insemination: is it an effective treatment for male factor infertility?

Results were collected from 11 studies comparing intrauterine insemination (IUI) with intracervical insemination (ICI) of frozen donor semen, 10 studies comparing IUI with timed natural intercourse (NI) or ICI in couples with semen defects and seven studies comparing ICI with NI or ICI in couples with unexplained infertility. IUI significantly increased the pregnancy rate relative to favourably timed ICI in donor insemination (DI) with frozen semen both with and without gonadotrophin stimulation of the female partner (odds ratios (95% confidence interval) 1.92 (1.02-3.61) and 2.63 (1.52-4.54) respectively). The benefit of IUI tended to be less when the pregnancy rate for ICI was high and IUI had no benefit with fresh donor semen. Overall IUI was of significant benefit in the male factor couples compared with NI-ICI (odds ratio 2.20 (1.43-3.39) and the advantage appeared to be maintained when comparison was confined to properly timed ICI although the odds ratios were not significantly greater than 1. IUI had no benefit relative to favourably timed NI-ICI for couples with unexplained infertility; an apparent advantage overall was produced by studies where NI was late. None of the studies on male factor used a sperm function test to define male subfertility and three only included couples with good mucus penetration by sperm. The range of semen defects defined was such that many couples would have had a good chance of conceiving naturally given a normal female partner but nevertheless the overall pregnancy rate (4.8%) was considerably less than in the unexplained group (11.6%), suggesting that some sperm dysfunction was present. We conclude that the available evidence suggests that IUI is valuable for DI with cryopreserved semen and for couples with mild to moderately impaired semen quality and postulate that it overcomes failure to fertilize due to impaired mucus penetration and poor survival in the female reproductive tract.     

Magnetic resonance imaging for the investigation of knee injuries: an investigation of preferences

Subdural hygroma (SDG) is a common post-traumatic lesion. Despite its common occurrence, the pathogenesis and clinical significance are uncertain. The author reviewed the literature to clarify the present knowledge on the pathogenic, diagnostic and therapeutic aspects of this controversial lesion. A trivial trauma can cause a separation of the dura-arachnoid interface, which is the basic requirement for the development of a SDG. If the brain shrinks due to brain atrophy, excessive dehydration or decreased intracranial pressure, fluid collection may develop by a passive effusion. Most SDGs resolve when the brain is well expanded. However, a few SDGs become chronic subdural haematomas, when the necessary conditions persist over several weeks. Since the majority of patients with a SDG do not show a mass effect, surgery is rarely required. Outcome is closely related to the primary head injury not to the SDG itself. The complexity of SDG depends on various factors including the dynamics of absorption and expansion, duration of observation, and indication and rate of surgery, besides variety of the primary head injury in types and severity. SDG is a common epiphenomenon of head injury.     

Ileoanal anastomosis for ulcerative colitis: results of an evolutionary surgical procedure

BACKGROUND/AIMS: Proctocolectomy with ileoanal anastomosis (IAA) has proved to be the most suitable surgical treatment for ulcerative colitis. The aim of this study was to compare the results of IAA according to the evolution of surgical procedures and particularly to compare the results of stapled versus hand-sewn anastomosis. METHODOLOGY: From 1984 to 1996, 37 men and 31 women were operated on in our centre for ulcerative colitis. The anastomosis between the J pouch and the dentate line was handsewn in 35 patients (group 1) and stapled in 33 patients (group 2). RESULTS: The mean operative time was significantly shorter in group 2 as compared with group 1 (265+/-59 vs. 323+/-53, p<0.01, respectively), whereas morbidity and functional results were comparable in both groups. In 10 patients with stapled IAA, a diverting ileostomy was not performed and the morbidity in this group did not increase. CONCLUSIONS: These results suggest that stapled IAA anastomosis is a safe procedure. The stapling technique of IAA simplifies total excision of the rectum and could mean that a diverting ileostomy is not necessary.     

Recombinant follicle-stimulating hormone: new biotechnology for infertility

The frequency of infertility in developed countries is approximately 8-10%. New drugs are available for assisted reproduction techniques. Two recombinant follicle-stimulating hormone (FSH) products, follitropin-beta (Follistim in the United States, Puregon in Europe) and follitropin-alpha (Gonal-F), join compounds derived through transfecting nonhuman cell lines with genetic material capable of replicating identical amino acid sequences to human compounds. The cell line used for recombinant (r)-FSH production is the Chinese hamster ovary (CHO). Previously, the only agents that showed benefit in controlled ovulatory stimulation were derived from the urine of menopausal women. Those compounds contain additional substances, such as urinary proteins and various amounts of luteininzing hormone. The amino acid sequence of r-FSH is identical to that of human FSH, but the two recombinant products exist in many different isoforms and differ from each other and from human FSH due to varied carbohydrate side chains. Due to variation in the carbohydrate side chains, follitropin-beta in solution has a higher pH than urine-derived FSH, which enhances receptor affinity and therefore is a greater inducer of folliculogenesis. Follitropin-beta does not cause endogenous production of anti-CHO or anti-FSH antibodies, and is well tolerated.     

Clinical evaluation of an immunoinhibition procedure for creatine kinase-MB

We have clinically evaluated the Dade "Cardiozyme" immunoinhibition procedure for determination of creatine kinase isoenzyme MB (CK-MG) in 71 patients who were suspected of having had an acute myocardial infarction. Electrophoresis for CK-MB was also carried out. On the basis of diagnostic sensitivity and specificity for myocardial infarction, we found the Dade procedure for CK-MB to be somewhat inferior to electrophoresis. In 11 patients for whom the time of infarction was known, we observed normal CK-MB results for two of them by both immunoinhibition and electrophoresis during the first 24 h, but subsequently could detect abnormal CK-MB results by both methods. Thus in some patients such data are not helpful for making a diagnosis in the first 24 h. The Dade procedure is easy to perform, but lacks sensitivity in the region of low CK-MB activity, requires a very stable spectrophotometer, is imprecise, and produces negative numerical results in patients without myocardial infarction.     

Temporary gastrostomy as an alternative procedure for nasogastric suction

Based on personal experience with 70 cases of temporary tube gastrostomy - used as an alternative procedure to nasogastric suction in 50 cases and as a double-purpose tube in 20 cases of radical esophagectomy - pertinent problems concerning indication, technique, advantages, and possible complications are presented. The results indicate that temporary gastrostomy is a safe procedure, reduces cardiopulmonary disorders, and increases the patient's comfort. The procedure is therefore strongly recommended for patients with poor cardiopulmonary reserve and for the age group above 60 years. Temporary gastrostomy is also indicated in younger patients, if prolonged gastric distension with the necessity of decompression is anticipated.     

Breast cancer: axillary dissection--or an unnecessary procedure?

The status of the axillary lymph nodes is one of the most important prognostic factors in breast cancer. The presence or absence of metastatic lymph nodes is of primordial importance for the choice of adjuvant therapy. Early diagnosis of breast cancer, a result of widespread use of screening mammography, has increased considerably the number of detected in situ cancer and small invasive cancer without involved lymph nodes. Up to now there exists no conclusive study concerning the curative value of axillary dissection. In contrast, the complications of this procedure, especially in the long run, are non-negligible, creating controversy over its use. In situ carcinoma is no longer considered an indication for axillary dissection, nor is micro-invasive cancer (< or = 2 mm). In absence of accurate imaging and valid alternatives to exploratory surgery, new less traumatising procedures are currently under investigation: axillary fat aspiration with endoscopic axillary surgery, or the sentinel lymph node biopsy which is enlarged in case of a positive histology to a full axillary dissection. This approach will permit in the near future a reduction of morbidity to a strict minimum due to surgical treatment in the node-negative patient.