Abdominal pregnancy. Review of current management

Two case reports of intraabdominal pregnancy and review of 9 others which have been seen at the Indiana University Hospital are presented. An incidence of one intraabdominal pregnancy in 7931 deliveries at Indiana University is compared to 1 in 3372 deliveries from a large series at another institution. A perinatal mortality of 91% and a maternal mortality of 18% from our series are contrasted to 90% and 6%, respectively, from the world literature. The diagnosis, management, and outcome of this rare form of extrauterine pregnancy are discussed. Recurrent abdominal pain in the gravid patient may signal abdominal pregnancy. The role of ultrasound in diagnosis and the importance of early surgical intervention with minimal disturbance of the placenta are stressed. In cases of intraabdominal pregnancy, the infant rarely survives and congenital malformations are frequent.     

Inhibition of fibroblast proliferation by human iris pigment epithelial cells in vitro: preliminary results

BACKGROUND: Endometriosis has been observed in 8-15% of reproductive age women and is commonly found in pelvic and nonpelvic organs. Despite its widespread prevalence, the etiology remains obscure. CASE: A 22-year-old woman with intractable epigastric and pelvic pain who was treated previously by laser ablation for pelvic and diaphragmatic endometriosis was referred to our clinic. The patient received leuprolide acetate for six months, but the symptoms did not improve. Second-look laparoscopy revealed deep endometriotic spots involving both the diaphragms, exactly in the line of the left ventricle. With visualization, endometriosis was excised in total with the help of hydrodissection and CO2 vaporization. CONCLUSION: As in pelvic endometriosis, therapy for extrapelvic endometriosis consists of surgical and hormonal manipulation following the diagnosis. The importance of extreme caution, meticulous surgery and cardiothoracic consultation when treating the diaphragmatic surface cannot be overemphasized.     

Levels of tumor necrosis factor alpha, gamma interferon, and interleukins 4,6, and 10 as determined in mice infected with virulent or attenuated strains of Trypanosoma cruzi

The incidence of puerperal ovarian vein thrombosis is estimated to range between 1 in 600 and 1 in 2000 deliveries. The cardinal signs of puerperal ovarian vein thrombosis include fever, leukocytosis, and right lower quadrant abdominal pain, most often in a recently delivered female patient. These patients are classically described as failing to improve with intravenous antibiotic therapy alone; resolution of symptoms and presumptive diagnosis is made on defervescence with the addition of intravenous heparin therapy. Objective diagnostic modalities include venography, ultrasound, laparoscopy, and MRI, although CT remains the gold standard for the identification of this under-diagnosed entity. We present a case report of a 20-year-old female treated at our facility for puerperal ovarian vein thrombosis. She was transferred to our vascular surgery service after developing the classic signs of puerperal ovarian vein thrombosis and undergoing CT demonstrating ovarian vein thrombosis with extension of free-floating thrombus into her inferior vena cava (IVC). This degree of thrombosis was particularly concerning when one considers the 3 to 33 per cent rate of pulmonary embolism reported in patients with puerperal ovarian vein thrombosis. Treatment modalities for such extensive degrees of thrombosis are described in the literature and range from hysterectomy and thrombectomy to ligation of the IVC. In our case, we prophylactically placed a suprarenal IVC Greenfield filter to protect against pulmonary embolism and proceeded with the standard regimen of anticoagulation and antibiotics. This treatment approach has been reported only twice previously in the literature, to our knowledge.     

The predictive value of electrodiagnostic studies in carpal tunnel syndrome

In recent years, electrodiagnostic studies have become an expected component in the work up and evaluation of carpal tunnel syndrome. We conducted a retrospective review of 460 carpal tunnel decompressions to determine whether the accuracy of diagnosis and the prediction of therapeutic outcome could be related to the positivity and severity of findings on preoperative electrical studies. The 349 patients (460 hands) were divided into two groups: group 1 consisted of hands with the clinical diagnosis of carpal tunnel syndrome but with normal electrodiagnostic studies (n = 62); in group 2 the hands had a clinical diagnosis of carpal tunnel syndrome with confirmatory electrodiagnostic studies (n = 398). The number and distribution of signs and symptoms of carpal tunnel syndrome were not statistically different between these two groups. There was not a statistically significant difference in the success rate of surgery or the incidence of complications. The similarities between these two groups suggests that the distinction between them (the positivity of electrodiagnostic studies) is an artificial one and that the clinical diagnosis of carpal tunnel syndrome is sufficient to predict the presence of the disease, as well as outcome of surgery. On the basis of these data, strict adherence to electrodiagnostic studies to confirm the diagnosis will exclude 13 percent of the patients with legitimate carpal tunnel syndrome from receiving appropriate therapy.     

In vitro fertilization versus tubal surgery: is pelvic reconstructive surgery obsolete?

OBJECTIVE: To compare the results of pelvic reconstructive surgery with cumulative success rates of IVF for couples with tubal factor infertility. DATA RESOURCES: Outcomes of pelvic surgery were obtained from a review of articles from the literature identified by directed Medline searches. Cumulative pregnancy rates of 771 couples with tubal factor infertility treated at the Cornell IVF program between December 1989 and December 1992 were calculated by life-table analysis. RESULTS: Overall delivery rate per transfer for patients with tubal factor was 28.9% (303 deliveries per 1,048 transfers) and did not appear to be affected significantly by the presence of a secondary diagnosis. A significant decline in pregnancy rates was observed with advancing age: age < 30 years, 48.4%; 30 to 34 years, 44%; 35 to 38 years, 28%; 39 to 40 years, 20%; 41 to 42 years, 9%; and > 42 years, 4.3%. Cumulative pregnancy rates for cycles 1 to 4 were 32%, 59%, 70%, and 77%, respectively, in patients with only tubal factor, and 28%, 55%, 62%, and 75% in patients with tubal combined with other associated infertility factors. CONCLUSIONS: Our experience suggest that > 70% of women with tubal factor infertility will have a live birth within four cycles of treatment with IVF. These results compare favorably with the best outcomes after tubal reconstructive surgery. In older women, because of the rapid decline of fertility potential with advancing age, efforts should be directed toward the treatment method that provides the highest likelihood of success within the shortest time interval.     

In vitro and in vivo antifungal activity of amphotericin B lipid complex: are phospholipases important?

BACKGROUND: Second primary malignancies are common after bilateral retinoblastoma; their estimated incidence has been as high as 51% 50 years after diagnosis. Fifteen patients who developed sebaceous gland carcinoma after radiation therapy have been reported in the literature, five of whom were treated for bilateral retinoblastoma. METHODS: The authors conducted a retrospective chart review of patients treated for bilateral retinoblastoma at Duke University Medical Center who later developed sebaceous gland carcinoma. RESULTS: This article reports two patients who developed sebaceous gland carcinoma after radiation therapy for bilateral retinoblastoma. CONCLUSIONS: Delay in diagnosis is often associated with sebaceous gland carcinoma. Because high mortality is observed with metastatic disease, the recognition of this association is important for anyone who follows patients with a history of bilateral retinoblastoma or prior cranial radiation therapy.     

Investigations for chronic pelvic pain

Chronic pelvic pain (CPP) is a common problem with a prevalence of about 38/1000 among women aged 20–50 years. The main gynaecological diagnoses include endometriosis, pelvic inflammatory disease and adhesions. The most common gastrointestinal diagnosis is irritable bowel syndrome and genitourinary diagnosis includes pathology such as interstitial cystitis. It is a challenge instigating the right investigations for patients with chronic pelvic pain because there is a considerable symptom overlap. They also have a higher prevalence for symptoms such as dysmenorrhea and dyspareunia. In this review, we aim to discuss the clinical consultation necessary to help us decide upon which investigative tools we need to use to help diagnose the cause(s) of CPP, although one needs to stress that a specific cause may not be found in patients with CPP and symptom focused multidisciplinary management of CPP is at least as important as diagnosis of specific pathology and disease focused treatment.     

A population study of the natural history of Wolff-Parkinson-White syndrome in Olmsted County, Minnesota, 1953-1989

BACKGROUND: Virtually all natural history studies of Wolff-Parkinson-White (WPW) syndrome have been case series and, as such, have been constrained by referral biases, skewed age and sex distributions, or brief follow-up periods. The purpose of our study was to examine the natural history, the development of arrhythmias, and the incidence of sudden death in an entire cohort of pediatric and adult WPW patients from a community-based local population. METHODS AND RESULTS: We identified 113 residents of Olmsted County, Minnesota, during the period 1953-1989 using the centralized records-linkage system provided by the Mayo Clinic and the Rochester Epidemiology Program Project. Medical records and ECGs were reviewed to confirm the diagnosis and to establish pathway location by ECG criteria. Follow-up, via record review and telephone interview, was complete in 95% of subjects through 1990. The incidence of newly diagnosed cases was approximately four per 100,000 per year. Preexcitation was not present on the initial ECG of 22% of the cohort. Approximately 50% of the population was asymptomatic at diagnosis, with 30% subsequently having symptoms related to arrhythmia at follow-up. Two sudden cardiac deaths (SCD) occurred over 1,338 patient-years of follow-up, yielding an overall SCD rate of 0.0015 (95% confidence interval, 0.0002-0.0054) per patient-year. No SCD occurred in patients asymptomatic at diagnosis. CONCLUSIONS: The incidence of sudden death in a local community-based population is low and suggests that electrophysiological testing should not be performed routinely in asymptomatic patients with WPW syndrome. Nevertheless, young, asymptomatic patients, particularly those < 40 years old, should return for medical follow-up should symptoms develop.     

The role of estrogen in female urinary incontinence and urogenital aging: a review

Urogenital aging is a complex of urogenital symptoms involving the lower urinary tract, the genital tract and the pelvic floor. These symptoms involve hypoestrogenism in the menopausal woman. This review concludes that irritative urinary and local vaginal symptoms are quite amenable to estrogen therapy. Urinary incontinence is thought to be benefited by treatment with estrogen, although controversy exists. There is a limited role for estrogen in problems of urogenital prolapse, rectal symptoms, and sexuality in menopause.     

Enhancement of aflatoxin B1-induced enzyme altered hepatic foci in rats by treatment with carbon tetrachloride

Hysterectomy is the second most commonly performed major operation in the United States. Approximately one in three women will have this operation, resulting in 590,000 procedures per year. The most common indications for hysterectomy are leiomyomata uteri, abnormal uterine bleeding, endometriosis, pelvic pain, and pelvic organ prolapse. Although hysterectomy is an appropriate therapeutic option for some women with these conditions, in many instances less radical alternatives may be offered. Leiomyomata may be managed expectantly if symptoms are not bothersome; for women with troubling leiomyomata symptoms, alternatives to hysterectomy include: endoscopic removal or destruction of myomas, arterial embolization, or hormonal therapy to inhibit or modify bleeding. Endometriosis and abnormal uterine bleeding of leiomyomata are both amenable to hormonal therapy. Pelvic pain is most effectively approached with a thorough evaluation (particularly for nongynecologic illness), with specific therapy directed at the cause of the pain. Pelvic organ prolapse may respond symptomatically to pelvic floor exercises, or to the use of a pessary. After alternatives to removal of the uterus are discussed, the informed woman may decide that hysterectomy is the option best suited to her. It is unusual for hysterectomy to be her only option.     

Clostridium difficile colitis associated with chronic renal failure

BACKGROUND: Clostridium difficile-associated diarrhoea (CDAD) is a potentially life-threatening illness which has been shown to be more common and more severe in patients with chronic renal failure (CRF) than in other groups. A review of CDAD in our nephrology unit was carried out. METHODS: A review of microbiology and histology records identified 32 cases of CDAD in the nephrology unit over a 24-month period. Patient notes were reviewed to identify risk factors, clinical features and outcome. Available isolates of C. difficile underwent 16S ribosomal RNA typing. RESULTS: The incidence of CDAD in the nephrology unit was 10.7 per 1000 admissions, compared to 2.7 per 1000 in other areas of the hospital (P<0.0001). CDAD was considered the sole or principal cause of death in six (19%) and was considered a contributing factor in a further seven (22%). Mortality was significantly higher among patients with established CRF (P=0.04). Seven cases occurred as a cluster, over a 1-month period. Isolates from this cluster, along with comparative strains from other areas of the hospital, were found to be PCR type 1. Diarrhoea occurred in 28 (89%) of cases, pyrexia in 17 (53%) and ileus or abdominal pain in 14 (44%). Six patients responded to discontinuation of antibiotics alone and 22 required metronidazole and/or vancomycin. Three patients had colectomy and one caecostomy because of toxic megacolon. Four patients died before specific therapy could be given and in two of these cases the diagnosis was made at autopsy. Twenty-six patients had a record of recent antibiotic therapy. Of these, 15 had at least one agent considered to be inappropriate (excessively broad spectrum agent in 11, excessive duration of therapy in four). Nine patients had only received antibiotics prior to admission. CONCLUSIONS: CDAD carries a high mortality in nephrology patients, especially those with established CRF. The diagnosis may be missed if a careful antibiotic history is not taken, including agents received prior to admission. Rational antibiotic prescribing and adherence to infection control measures are vital to reduce the incidence of this serious condition.     

High prevalence of sexually transmitted diseases in women with urinary infections

OBJECTIVE: To determine the prevalence and factors associated with unrecognized sexually transmitted diseases (STDs) in women who had pelvic examinations and were subsequently released from the ED with a sole diagnosis of urinary tract infection (UTI). METHODS: A 3-month retrospective chart review was performed in an urban teaching hospital ED (> 70,000 visits/year). Women aged 12-45 years who had pelvic examinations and were released from the ED with a sole diagnosis of UTI were included. Patient complaints, physical findings, and laboratory results were reviewed. Laboratory evaluations included the complete blood count, urinalysis, urine pregnancy test, and cervical cultures for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas. RESULTS: Of the 94 women who met study criteria, 53% had proven STDs (19% N. gonorrhoeae, 22% C. trachomatis, 33% Trichomonas). There was no difference between the patients with positive and negative tests for STDs with regard to complaints, physical findings, and laboratory results (all p > 0.05). CONCLUSIONS: Women undergoing pelvic examinations who are subsequently released from this urban ED with the diagnosis of UTI have a high (> 50%) prevalence of occult STDs. No complaint, physical finding, or laboratory result reviewed was associated with the risk of an STD. Consideration should be given to empirical antibiotic therapy in similar urban populations.     

Endodermal sinus tumor and embryonal carcinoma of the ovary in a 53-year-old woman

BACKGROUND: Germ cell tumors, the most common ovarian malignancies in females under the age of 21, are rare in older women. We report an unusual case of a mixed embryonal carcinoma and endodermal sinus germ cell tumor in a perimenopausal patient and review the differential diagnosis and management of these malignancies with respect to age. CASE: A 53-year-old woman complaining of irregular menses and pelvic pain was found to have a large pelvic mass and a positive pregnancy test. Subsequent investigation revealed a large left adnexal mass, and an elevated beta-HCG and alpha-AFP. At laparotomy, a mixed germ cell tumor was found. The patient was treated with multiagent chemotherapy and currently is without evidence of disease. CONCLUSION: Although rare, the diagnosis of germ cell tumor should be considered in older women presenting with a large pelvic mass. The treatment and prognosis is similar regardless of age, except that reproductive-sparing surgery is not a priority in the older patient.     

Rolandic epilepsy: an incidence study in Iceland

PURPOSE: We wished to determine incidence, clinical features, and prognosis of benign rolandic seizures (BRS) and benign rolandic epilepsy (BRE) in a total population. METHODS: Cases were ascertained through review of all EEG records, and diagnosis was verified by review of medical records. Follow-up information regarding seizures and treatment was obtained from parents and treating physicians. RESULTS: In the Icelandic population aged 3-15 years, the incidence of BRS is 6.2 and BRE 4.7 in 100,000. Five years after onset 95% were seizure-free. At last follow-up, all were seizure free and had not been treated with antiepileptic drugs (AEDs) for at least 1 year. CONCLUSIONS: Our study demonstrates that BRS is a common entity in children. The prognosis is excellent and treatment is not necessary in all cases. It is important to identify BRE/BRS correctly and distinguish it from other types of epilepsy.     

Acute poisoning with amphetamines (MDEA) and heroin: antagonistic effects between the two drugs

BACKGROUND: While pelvic arterial insufficiency, either acute or chronic, results in stereotypic clinical findings which may readily be reversed by indirect techniques of revascularization, few reports document the indications for, techniques of, and results following direct pelvic revascularization by reconstruction of the hypogastric artery. METHODS: Retrospective review of 8 patients with symptomatic pelvic arterial insufficiency undergoing direct hypogastric artery reconstruction during the period from 1984 to 1995. RESULTS: Eight patients underwent unilateral hypogastric artery reconstruction by bypass graft (3 patients) or endarterectomy and patch angioplasty (5 patients). One patient had immediate symptomatic relief of his symptoms, but was lost to follow-up after 1 month. One patient manifested no symptomatic improvement despite a technically successful operation. The remaining 6 patients experienced significant symptomatic relief that has persisted during follow-up from 3 months to 11 years postoperatively. Among 4 men in whom erectile impotence comprised one of the indications for intervention, 3 reported sustained restoration of sexual function. CONCLUSION: In properly selected patients, direct pelvic revascularization by hypogastric artery reconstruction may predictably and durably relieve symptoms of pelvic arterial insufficiency.     

Integrated services for treatment of schizophrenic substance abusers: demographics, symptoms, and substance abuse patterns

We have previously described a model of outpatient integrated treatment for patients with comorbid psychoactive substance use disorders and schizophrenia (PSUD/S)(1). Here we review relevant literature on comorbidity and outline the rationale for integrated services. Further, we describe results from 3 related studies: First, we document the approximate incidence of PSUD among a heterogeneous group of 602 schizophrenic inpatient admissions to our hospital. Second, we describe in greater detail the psychiatric symptoms and patterns of substance abuse among a subsample of 106 inpatients with PSUD/S, contrasting them with 112 patients with PSUD and mixed psychotic disorders, but who are not schizophrenic. Third, we present a prospective research project and describe a sample of 30 patients with PSUD/S, detailing demographic characteristics, psychiatric symptoms and substance abuse history. Attention is given to current issues in the differential diagnosis of patients with PSUD/S using standardized instruments.     

Psychiatric hospitalization of adolescents for conduct disorder

OBJECTIVE: The authors' goal was to review current published literature on the psychiatric hospitalization of adolescents with a diagnosis of conduct disorder. METHODS: The English-language literature from 1980 to 1991 cited in the MEDLINE database was searched using the key words conduct disorder, adolescent psychiatric hospitalization, psychiatric hospitalization criteria, adolescent psychiatric inpatient hospitalization, and adolescent psychiatric admissions. RESULTS: A diagnosis of conduct disorder or presenting symptoms and behaviors consistent with that diagnosis are commonly reported for adolescent psychiatric admissions. Estimates of the percentage of admissions to psychiatric inpatient treatment facilities of adolescents with conduct disorder or symptoms consistent with that disorder range from 30 to 70 percent. There are no research-based criteria for hospitalization of adolescents for conduct disorder, and systematic studies of the outcome of psychiatric hospitalization for this group have not been published. Comorbid psychiatric diagnoses and similar behavioral symptoms in conduct disorder and comorbid disorders complicate inpatient treatment of adolescents with conduct disorder. CONCLUSIONS: Studies of the outcome of psychiatric hospitalization of adolescents for conduct disorder are needed to determine the appropriate use of this modality.     

The Saint syndrome]

In connection with two cases authors review our current body of knowledge on Saint's triad that means the concomitant occurrence of cholelithiasis, hiatus hernia and colonic diverticulosis. Though each component of this syndrome is fairly common, the Saint's triad is relatively seldom encountered. It does happen so because not all the components are likely to cause clinical symptoms. Consequently diagnosis and subsequent therapy are targeted at the dominating symptoms. On the other hand, the existence of the syndrome is also not sufficiently known in clinical practice. Authors stress that in the event of simultaneous symptoms suggestive of atypic cholelithiasis, colonic diverticulosis and hiatus hernia one has to consider a potential Saint's triad. Therefore it is recommended to verify or exclude each of the three components to establish a precise diagnosis and adequate subsequent therapy.