Levels and trends of smokeless tobacco use among youth in countries of the World Health Organization South-East Asia Region

BACKGROUND

At least two rounds of the Global Youth Tobacco Survey (GYTS) have been completed in most of the countries in the World Health Organization South-East Asia region. Comparing findings from these two rounds provides trend data on smokeless tobacco (SLT) use for the first time.

METHODS

This study uses GYTS data from Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste during 2006-2013. GYTS is a nationally representative survey of 13-15-year-old students using a consistent and standard protocol. Current SLT use is defined as using any kind of SLT products, such as chewing betel quid or nonbetel quid or snuffing any other products orally or through the nasal route, during the 30 days preceding the survey. Prevalence and 95% confidence intervals were computed using SAS/SUDAAN software.

RESULTS

According to most recent GYTS data available in each country, the prevalence of current use of SLT among youth varied from 5.7% in Thailand to 23.2% in Bhutan; among boys, from 7.1% in Bangladesh to 27.2% in Bhutan; and among girls, from 3.7% in Bangladesh to 19.8% in Bhutan. Prevalence of SLT was reported significantly higher among boys than girls in Bhutan (boys 27.2%; girls 19.8%), India (boys 11.1%; girls 6.0%), Maldives (boys 9.2%; girls 2.9%), Myanmar (boys 15.2%; girls 4.0%), and Sri Lanka (boys 13.0%; girls 4.1%). Prevalence of current SLT use increased in Bhutan from 9.4% in 2009 to 23.2% in 2013, and in Nepal from 6.1% in 2007 to 16.2% in 2011.

CONCLUSION

The findings call for countries to implement corrective measures through strengthened policy and enforcement.

Effects of a pediatric emergency department febrile infant protocol on time to antibiotic therapy

The purpose of this study was to examine the effect of an Emergency Department (ED) protocol to reduce time to antibiotic administration in the febrile infant less than 3 months of age with a rectal temperature > or =38.0 degrees C. We conducted a before-after study of a febrile infant quality improvement initiative in an urban pediatric ED with approximately 35,000 patient visits per year. Records of infants less than 3 months of age presenting with a rectal temperature > or =38.0 degrees C, who underwent a full septic work-up (blood, urine, and cerebrospinal fluid studies, and possibly chest radiography), were identified by using daily ED logs. This review was performed in the month before and then 12 months after institution of the "Septic Infant Work-up Sheet" and a set of interventions (Febrile Infant Protocol) designed to streamline care of the febrile infant and to reduce the time to antibiotic administration. Data were analyzed by using the Kaplan-Meier survival estimate and the log-rank test. Patient demographic characteristics and severity of illness were similar across months; however, ED process of care was significantly changed. Initial analysis revealed a median time to antibiotics of 142 min. Subsequent analysis after implementation of the Febrile Infant Protocol revealed a median time to antibiotics of 105 min. This represents an overall time reduction of 25% from time of presentation to antibiotic administration. In conclusion, a guideline-based ED febrile infant protocol changed clinical practice and improved time to antibiotics.

Foster parents of medically fragile children can improve their BLS scores: results of a demonstration project

OBJECTIVES

1) To assess performance and comfort level with cardiopulmonary resuscitation (CPR), foreign body removal (FBR), and seizure management in foster parents of medically fragile children; 2) To determine if the parents' performance and comfort levels increase with an individual teaching session with a medical professional to review CPR and FBR.

METHODS

In this single cohort pilot study, 18 foster parents of medically fragile children were asked to rate their comfort level with pediatric CPR and FBR on a 5-point scale (1 = very uncomfortable, 5 = very comfortable). They then underwent five mock code scenarios and were evaluated using a 5-point scale (1 = poor performance, 5 = outstanding performance). A 6-month follow-up evaluation using similar scenarios was conducted.

RESULTS

At visit 1, the percentage of parents demonstrating adequate performance of CPR, FBR, and seizure management was: 1) CPR: infant (78%); child (78%); 2) Foreign body removal: age <1 year (17%); age >1 year (65%); 3) Seizures (94%). At visit 2, performance improved in all areas, especially FBR, where the percentage of parents demonstrating adequate performance increased to 71% for children <1 year and 82% for children >1 year. As measured by the 5-point scales, CPR and FBR performance and parent comfort level with CPR improved significantly (Wilcoxon signed-ranks test, P < 0.004), but parent comfort level with FBR did not (P = 0.12).

CONCLUSIONS

Based on this pilot study, foster parents of medically fragile children benefit from an individual teaching session by a medical professional. CPR instruction for this group of foster parents should include adequate review and assessment of foreign body removal procedures.

Intrathoracic petechiae in sudden infant death syndrome: relationship to face position when found

Previous studies have not addressed the relationship of intrathoracic petechiae (IP) to the position of the face when a caretaker finds a victim of sudden infant death syndrome (SIDS). The aims of this retrospective study were to determine (1) the rate of the facedown position in SIDS (not to be confused with the prone body position), (2) if the facedown position occurred more frequently among SIDS victims with intrathoracic petechiae than those without petechiae, and (3) if the facedown position occurred more frequently among cases with more severe petechial hemorrhage of the thymus. We selected 199 SIDS cases from the San Diego SIDS Research Project database and grouped them as IP-present and IP-absent. Each case was analyzed with regard to the face position when found unresponsive or dead. Among these 199 cases, 37% were found face-down, which represents 51% of the 142 cases found prone. The two groups were similar with respect to age, sex, and rate of premature birth. Thirty-nine percent (39%) of the IP-present group and 9% of the IP-absent group were found in the facedown position (P = 0.057; 95% confidence interval for the difference = 0.3%, 40%). Cases were also grouped by severity of thymic petechiae and analyzed regarding face position. Neither age nor the facedown position was associated with greater severity of thymic petechiae. The wide confidence interval yielded by our analysis of IP limits our ability to clarify the precise pathophysiologic role of external oronasal obstruction in SIDS. While it remains possible that a subset of SIDS cases occur as a result of external obstruction, we are unable to generalize its importance. Internal airway obstruction and rebreathing with terminal gasping, both of which have been documented in sudden infant death, remain other possible scenarios leading to the production of IP.

Neck extension and rotation in sudden infant death syndrome and other natural infant deaths

It has been hypothesized that some cases of sudden infant death syndrome (SIDS) are a result of neck extension and/or rotation that causes vertebral artery (VA) compression and brain stem ischemia. There is a paucity of relevant literature on this topic. Therefore, our aim was to compare neck rotation and extension in SIDS and other natural infant deaths. Cases of SIDS and other natural infant deaths within the San Diego SIDS Research Project database were analyzed retrospectively with respect to neck and body position as reported by the trained, experienced scene investigators and/or the caretakers who discovered the infants. Information was used from 246 SIDS cases and 56 cases of other natural deaths. Simultaneous neck extension and rotation was not reported in either group. When data regarding neutral/flexed/extended position and rotation of the neck were combined, no significant differences were found between the two groups (P = 0.94); 40% of the SIDS cases and 41% of the other natural death cases were found with the neck either extended or rotated (odds ratio [OR] 0.97, [reference group = neck either neutral or flexed, and not rotated], 95% confidence interval [CI] 0.45, 2.11). There were also no significant differences between the groups when neck rotation and neck extension were analyzed independent of one another. Neck rotation among cases found in the prone position was common and was not significantly different between the two groups (49% of 146 SIDS cases, 58% of 24 other natural death cases, P = 0.38, OR 0.68, 95% CI 0.28, 1.62). Neck rotation among infants found in the supine position occurred one-third as often in the SIDS group (9% of 33 cases) as in the other natural death group (29% of 14 cases); however, the difference was not significant (P = 0.17; OR 0.25, 95% CI 0.05, 1.31). Although our analysis does not exclude VA compression and brain stem ischemia in some cases of SIDS, we found no evidence to affirm its importance. This study demonstrates the importance of meticulous scene descriptions, including neck position.

Successful treatment of retrograde ejaculation with sperm recovered from bladder washings. A report of two cases

BACKGROUND

Retrograde ejaculation causes < 2% of male infertility but is the leading cause of aspermia. The incidence of retrograde ejaculation is increasing due to the aggressiveness of modern urologic cancer surgery and an increase in diabetes mellitus. Generally, the only adverse effect is on fertility. Various approaches have been proposed for treatment, ranging from insemination with sperm-rich urine obtained after masturbation to intracytoplasmic sperm injection (ICSI). We used a protocol involving bladder washing.

CASES

Case 1 involved a man with retrograde ejaculation secondary to a successful right orchiectomy and retroperitoneal lymph node dissection for stage B1 embryonal cell carcinoma. He was treated with bladder washing and intrauterine insemination. He fathered three children from six insemination cycles. Case 2 involved a man with idiopathic retrograde ejaculation and a wife with ovulatory dysfunction. He received treatment similar to that in case 1 and fathered one child from two insemination cycles.

CONCLUSION

Larger studies need to be done specifically comparing treatments. Our method resulted in four normal infants in two couples over eight total insemination cycles and, taken together with other results from the literature, seems a good choice for clinicians who are treating retrograde ejaculation for the first time. We agree with others who have recommended that in vitro fertilization/ICSI not be the first step for treating the usual couples with retrograde ejaculation.

Laparoscopic removal of a perforated intrauterine device from the perirectal fat

BACKGROUND

The intrauterine device (IUD) was a very common form of birth control in the United States. The most serious potential complication of IUD use is uterine perforation. Uterine perforation is common among women with "lost" IUDs and can cause severe morbidity and mortality and should be carefully managed. The recommended treatment is removal of the perforating IUD. This can usually be managed laparoscopically unless bowel perforation or other severe sepsis is present.

METHODS

An intra-abdominal IUD was removed laparoscopically from the perirectal fat of a 49-year-old woman who had been diagnosed over 20 years earlier with an "expelled" IUD.

CONCLUSIONS

It is important that the possibility of uterine perforation be considered in anyone who has had a diagnosis of an expelled IUD without actual confirmation that the IUD is no longer present in the body. In any woman who presents with pelvic pain and a history of a "lost" IUD, the surgeon should have a high index of suspicion and obtain radiological studies. It may be advisable to question women about possible IUD use when they present with pelvic pain of unknown origin.

The effect of valproic acid on blood loss in patients with cerebral palsy

Valproic acid (VPA) is used in the treatment of seizure disorders often present in patients with cerebral palsy. The charts of 114 patients with cerebral palsy were reviewed to evaluate the effect of VPA on blood loss during spine surgery. Forty-one patients had seizure disorders. Of these, 18 were taking VPA as monotherapy (group III) and the remaining 23 patients were taking other antiseizure medications, including two taking VPA (group II). There was a significant increase in the number of patients with abnormal bleeding times and a significant difference (p < 0.001) in blood loss (ml/kg) in patients taking VPA as monotherapy (38.6 ml/kg vs. 30.0 ml/kg). There was also increased blood-product administration postoperatively in the VPA monotherapy patients. Physicians should be aware of this potential association between VPA use and increased blood loss. The routine laboratory tests of complete blood count, prothrombin time, and partial thromboplastin time will not adequately screen for the platelet-mediated effects of VPA.

Impact of lifestyle choices on female infertility

OBJECTIVE

To inform physicians who are involved in the primary care of reproductive-age women of the specific relationships between lifestyle choices and infertility so that they can use this knowledge to educate their patients and encourage changes in behavior.

STUDY DESIGN

A review of the relevant literature, performed via Medline search.

RESULTS

Prevention of chlamydial and gonorrheal infections; maintenance of the proper body weight; increased individual awareness about the effects of age on fecundity; and reduced intake of caffeine, tobacco and alcohol are all possible avenues for primary prevention of infertility.

CONCLUSION

Lifestyle choices can be made that influence the reproductive capability of women. It may be worthwhile for primary care physicians to use information on lifestyle to encourage their patients to improve their overall health while positively affecting their ability to reproduce.

Gamete intrafallopian transfer. A cost-effective alternative to donor oocyte in vitro fertilization in women aged 40-42 years

OBJECTIVE

To investigate whether gamete intrafallopian transfer (GIFT) may be a cost-effective alternative to donor oocyte procedures in women 40 and older with good ovarian reserve.

STUDY DESIGN

Retrospective review of records at an infertility clinic in a large multispecialty group practice. Twenty two consecutive women aged 40 and older underwent 24 stimulation cycles for laparoscopic GIFT procedures from 1988 to 1997.

RESULTS

The mean GIFT cycle cost was $5,731. The delivery rate per stimulation cycle was 25.0%. The patients who gave birth were 40-42 years of age. The mean cost per delivered infant was $22,924. A previously reported value for mean cost per pregnancy for donor oocyte in vitro fertilization (IVF) was $30,457. Theoretical costs per delivery, generated from Society for Assisted Reproductive Technology outcome data for anonymous donor oocyte IVF in 1994 (delivery rate per transfer, 34.4%) for $8,000, $9,000 and $10,000 cycle costs were $23,256, $26,163 and $29,070, respectively.

CONCLUSION

In women with good ovarian reserve, GIFT may be a cost-effective alternative to donor oocyte IVF at age 40-42.

Ice-cream truck-related injuries to children

Few studies exist on the cause and nature of injuries to children from ice-cream truck-related accidents. We reviewed the medical records of 11 children with orthopedic injuries treated at Children's Hospital-San Diego from 1985 to 1995 for injuries in such accidents. Of nine children on their way to or from an ice-cream truck who were struck by an oncoming vehicle, all were girls; eight had pelvic or lower-extremity fractures. When ice-cream trucks park on the street, they pose a danger to children, because children are drawn to them, and the trucks' large size blocks the vision of oncoming drivers.

Etiology of supracondylar humerus fractures

The specific etiology of supracondylar humerus fractures in children is not well known. All supracondylar humerus fractures treated at Children's Hospital and Health Center, San Diego (CHSD) over an 8-year period (n = 391) were reviewed to determine specific information about the manner in which the injury occurred. Girls tended to sustain these fractures more often, and the nondominant arm was more often injured. Falls from a height accounted for 70% of the fractures. Children < or = 3 years old tended to fall off of household objects (beds, couches, other objects 3-6 feet high), and children 4 years and older tended to fall from playground equipment such as monkey bars, slides, and swings. Safety precautions should be implemented in homes of young children and at playgrounds to avoid these fractures.

Laparoscopic removal of virilizing hilar cell tumor in a postmenopausal patient

A postmenopausal woman experienced rapidly progressing hirsutism and signs of virilization. Hormone evaluations showed markedly elevated serum testosterone levels and no evidence of excess cortisol or dehydroepiandrosterone sulfate production. A computerized tomographic scan of the adrenals and ovaries was normal, and transvaginal ultrasound revealed a left ovary with a maximum diameter of 3.2 cm. At outpatient laparoscopic bilateral oophorectomy, the left ovary had a benign, 2.5-cm Leydig cell tumor, hilar cell variant. Laparoscopy may be useful in the diagnosis and treatment of select cases of virilizing tumors of the ovary.

Improving the cost-to-benefit ratio of in-vitro fertilization

In-vitro fertilization (IVF) has been criticized for being too costly to permit ready access to needy patients, either through their own funds or through those of third party providers. European groups have managed to offer these procedures at a fraction of the cost incurred by their United States counterparts by streamlining their protocols. Accordingly, we present our methods for reducing the cost of IVF. The main modification was made by performing the IVF procedures in the clinic under i.m. analgesia, avoiding the costs of a surgery suite and anaesthesia. In addition, donor, oocyte, micromanipulation, and cryopreservation services were not offered, reducing overall personnel and equipment costs. Overall costs were reduced from customary levels of $7,000--$11,000 in the United States to $3,409 per cycle initiated, while maintaining good ongoing/delivered pregnancy rates (30.0% versus 18.6% nationally) per cycle reaching aspiration. We conclude that, through the elimination of less necessary and/or utilized procedures, IVF may be performed in a more cost-effective manner while maintaining good success rates. For the patients who desire IVF services not offered under such a system, referral to a more specialized IVF center is appropriate.

High-frequency pressure-control ventilation with high positive end-expiratory pressure in children with acute respiratory distress syndrome

OBJECTIVE

Animal models suggest that high-frequency ventilation with low tidal volumes and high positive end-expiratory pressure (PEEP) minimize secondary injury to the lung. We hypothesized that using a high-frequency pressure-control mode of ventilation with high PEEP in children with severe acute respiratory distress syndrome (ARDS) would be associated with improved survival.

DESIGN

The study was a retrospective and prospective clinical study at a 24-bed tertiary care pediatric critical care unit. Fifty-three patients with severe ARDS were studied during a 37-month period, 30 prospectively and 23 retrospectively. Severe ARDS was defined as (1) rapid onset of severe bilateral infiltrates of noncardiac origin, (2) partial pressure of oxygen (arterial)/fraction of inspired oxygen less than 200 on PEEP of 6 cm H2O or more for 24 hours or longer, and (3) Murray disease severity score greater than 2.5. All patients meeting these criteria underwent ventilation in the pressure-control mode; the protocol for ventilation had the following general guidelines: (1) fraction of inspired oxygen limited to 0.5, (2) mean airway pressure titrated with PEEP to maintain arterial partial pressure of oxygen of 55 mm Hg or greater (7.3 kPa), (3) peak inspiratory pressure minimized to allow hypercapnia (arterial partial pressure of carbon dioxide, 45 to 60 mm Hg (6.0 to 8.0 kPa), and (4) ventilator rates of 40 to 120/min. Percutaneous thoracostomy and mediastinal tubes were placed for treatment of air leak.

RESULTS

The survival rate was 89% (47/53) in children with severe ARDS. Nonsurvivors had significantly higher peak inspiratory pressures (75 vs 40 cm H2O, p = 0.0006), PEEP (23 vs 17 cm H2O, p = 0.0004), mean airway pressure (40 vs 28 cm H2O, p = 0.04), alveolar-arterial oxygen gradient (579 vs 540 mm Hg, p = 0.03), and oxygenation index (43 vs 19, p = 0.0008) than survivors. Air leak was present in 51% of patients; there was no difference in the incidence of air leak between survivors and nonsurvivors (p = 0.42).

CONCLUSIONS

The high-frequency positive-pressure mode of ventilation was safe and was associated with an improved survival rate (89%) for children with severe ARDS. Limitation of both inspired oxygen and tidal volume, along with aggressive treatment of air leak, may have contributed to the improved survival rate.

Outpatient minilaparotomy ovarian cystectomy for benign teratomas in teenagers

Benign cystic teratomas are the most common ovarian neoplasms in adolescents. An ovary-conserving method was developed for outpatient surgical removal of benign cystic teratomas by minilaparotomy in teenagers. The technique requires no specialized training, laser devices, or expensive disposable instrumentation. As a precaution, the first teenager in whom the technique was used was observed as an inpatient for 3 days. Following this, the method was used as an outpatient procedure in three further cases. No complications occurred in any of the four patients, and the mean operating time of 85 minutes (range, 60 to 95 minutes) was similar to the reported time for removal of benign cystic teratomas by laparotomy. Although a randomized controlled study with many more patients would be necessary for a definitive conclusion, considerable cost savings and reduction in morbidity over traditional laparotomy are suggested by this experience.

Laparoscopic diagnosis and treatment of an infarcted epiploic appendage

A patient experienced acute abdominal pain that was diagnosed at laparoscopy as being due to an infarcted epiploic appendage. To our knowledge, this is the second report of laparoscopic diagnosis and treatment of an epipolic disorder. Infarcted epiploic appendages may be associated with bowel obstruction and abscess formation. Therefore, they should be looked for at the time of diagnostic laparoscopy for acute abdominal pain of unclear etiology, and removed if present.

Peripheral joint laxity increases in pregnancy but does not correlate with serum relaxin levels

OBJECTIVE

Our purpose was to evaluate peripheral joint laxity during pregnancy and to determine whether serum relaxin levels are associated with increased joint laxity.

STUDY DESIGN

A prospective observational study was performed.

RESULTS

A significant increase in joint laxity was found in five of seven peripheral joints over the course of the pregnancy and post partum. There was no correlation with serum relaxin levels. There were no significant differences in joint laxity on the basis of parity, age, or prepregnancy exercise levels.

CONCLUSIONS

Peripheral joint laxity is noted to increase as pregnancy progresses. The cause of this change is undetermined.

Equal effectiveness of electrical and volitional strength training for quadriceps femoris muscles after anterior cruciate ligament surgery

Neuromuscular electrical stimulation and voluntary muscle contraction are two exercise modes widely used in rehabilitation to strengthen skeletal muscle. Since there is no debate as to which mode is most effective, we compared electrical stimulation with voluntary contraction performed at matched intensities following reconstructive surgery of the anterior cruciate ligament. Forty men and women, aged 15-44, were randomly assigned to either an electrical stimulation or a voluntary contraction group. None of the subjects had a previous history of neuromuscular injury. The subjects received treatment for 30 minutes a day, 5 days a week, for 4 weeks. Knee extension torque was monitored during treatment to try to match the absolute muscular tensions (quantified as "activity") achieved during therapy. To match the activity of the subjects in the electrical stimulation group, who were treated at the highest stimulation intensity they could tolerate, the subjects in the voluntary contraction group were paced at progressively increasing intensities corresponding to 15, 25, 35, and 45% of the injured limb's maximum voluntary torque during weeks 1, 2, 3, and 4, respectively. We found no significant difference between the groups in terms of maximum voluntary knee extension torque throughout the study period. In addition, 1 year after surgery, there was still no significant difference between groups with regard to knee extension torque (p > 0.4). These data suggest that neuromuscular electrical stimulation and voluntary muscle contraction treatments, when performed at the same intensity, are equally effective in strengthening skeletal muscle that has been weakened by surgical repair of the anterior cruciate ligament.

Factors associated with improving success rates with gamete intrafallopian transfer under thin-needle spinal anesthesia

PURPOSE

In order to reduce the risk of major anesthetic complications associated with laparoscopic gamete intrafallopian transfer procedures, we have exclusively used thin-needle spinal anesthesia over the years 1991 - 1994. This paper will review complication rates in order to further establish the safety profile of GIFT under thin-needle anesthesia and report the changes in our GIFT protocol from 1991 to 1994 which have been associated with a statistical improvement in the implantation rate from 11% to 23% (P = 0.01) and an increase in delivery rates from 29% to 42% per transfer procedure.

METHODS

Sixty-eight laparoscopic GIFT procedures were done in women with at least one patent oviduct and failure to respond to less invasive treatment. Clinical variables were analyzed to determine if similar patient populations had been treated over the study period.

RESULTS

The improved delivery rates and implantation rates could not be explained by patient selection. No major perioperative complications occurred. Minor perioperative complications and difficulties included one patient requiring general anesthesia, one patient developing a spinal headache which could be managed conservatively at home, and one patient requiring a minilaparotomy to complete the GIFT procedure. The more serious complications occurred as a result of the superovulation and multiple oocyte transfer rather than the surgical or anesthetic technique. These included two patients with severe ovarian hyperstimulation requiring hospitalization, and five delivered triplet pregnancies. Factors associated with improving success rates included improvements in semen and equipment preparation as well as an increase in the number of sperm transferred from 200,000 to 500,000.

CONCLUSIONS

GIFT can be performed with relative safety under thin needle spinal anesthesia with high implantation and delivery rates if care is made to optimize sperm and equipment preparation. GIFT under thin-needle spinal anesthesia may be an attractive alternative for treatment of longstanding nontubal infertility in couples willing to take the risk of ovarian hyperstimulation and multiple pregnancy.

Improved combined laparoscopic and minilaparotomy technique to allow for reversal of extensive tubal sterilization

We assessed the efficacy of combined laparoscopic and minilaparotomy for outpatient microsurgical reversal of extensive tubal sterilization in 11 women undergoing the procedure and followed for a mean of 24.7 months. All patients desired reversal of extensive tubal sterilization, and had 4 cm or less of the longer oviduct remaining. The mean operating time was 110 minutes, and the mean total cost was $5067. There were no major complications. Two women were treated for uncomplicated cystitis within 1 month of surgery. Five (45%) of 11 women delivered viable infants; one patient had two ectopic pregnancies. These preliminary data suggest that outpatient combined laparoscopy and minilaparotomy may be effective in patients who desire restoration of fertility after extensive tubal sterilization.

Serum parathyroid hormone-related protein levels during lactation

We measured parathyroid hormone-related protein (PTHrP) in the serum of 15 healthy women within three days of beginning breast-feeding and within one hour of completing nursing. A sensitive immunoradiometric assay that measures N-terminal PTHrP containing at least the first 74 amino acids was used. We found normal PTHrP values in all patients. Values one day before and two days after delivery in a hypoparathyroid woman who chose not to breast-feed were also normal. Since N-terminal PTHrP fragments of 1-36 amino acids or more are biologically active, we believe additional studies using sensitive PTHrP assays that measure smaller fragments and investigations performed under other conditions of breast-feeding are necessary before concluding that PTHrP does not have a role in calcium homeostasis in nursing mothers. Furthermore, additional studies in hypoparathyroid nursing mothers should be performed.

Laparoscopic treatment of heterotopic pregnancy

The increasing frequency of pelvic inflammatory disease and use of ovulation-induction agents has resulted in a corresponding increase in the frequency of heterotopic pregnancy. In most reported cases the diagnosis was made retrospectively at the time of laparotomy. With improvements in ultrasonography and operative laparoscopy, the diagnosis can be made preoperatively and the disease treated surgically with low morbidity. In a woman who had received clomiphene citrate for ovulation induction, the diagnosis of heterotopic pregnancy was suspected preoperatively based on transvaginal ultrasonography. The patient was treated laparoscopically by partial salpingectomy, and subsequently delivered a normal infant.

Spontaneously acquired, unilateral absence of the adnexa. A case report

A free-floating, calcified cyst was found in the peritoneal cavity in association with unilateral absence of the adnexa. The evidence was that it was due to torsion and separation of the adnexa from their supporting structures. This phenomenon may be a cause of congenital absence of the ovary.

Use of the Edinburgh Postnatal Depression Scale to identify postpartum depression in a clinical setting

The Edinburgh Postnatal Depression Scale (EPDS) is a validated instrument developed specifically to identify women experiencing postpartum depression (PPD). This study sought to determine the extent of postpartum depression in our population and the maternal characteristics associated with it and to also determine if the scale increased practitioner awareness and treatment of PPD. Two hundred eighty-seven women from the total population completing the EPDS in 1991 (n = 1,139) were randomly selected for retrospective chart review to identify relationships between maternal characteristics and elevated EPDS scores. Charts were also reviewed for outcomes related to depression for the six-month period after delivery. Statistical analysis of the data revealed that 17.4% of the total population had an EPDS score of > or = 10, indicating a potential risk of developing PPD. Eight percent scored > or = 13, suggesting that further assessment was necessary. Marital instability, lack of medical insurance and a history of depression were the factors found to correlate most significantly with elevated EPDS scores. The physicians and midwives providing service for our population were interviewed, and 83% reported that the EPDS had increased their awareness of PPD, while 92% reported having referred for treatment patients with high EPDS scores. Use of the EPDS scale can improve practitioner awareness and aid in the diagnosis of PPD. Several easily identifiable variables are associated with PPD.

Reproductive potential after treatment for persistent ectopic pregnancy

We examined the success rate and reproductive outcome of 50 patients who had been treated for persistent EP after initial unsuccessful salpingostomy. All who underwent salpingectomy had successful treatment of their persistent EP. One treatment failure occurred after MTX. Of 50 women, 32 (61.5%) attempted conception after treatment for persistent EP. The cumulative clinical pregnancy rate after treatment for persistent EP was 59% at 36 months. There was a significant association between clinical pregnancy rate after persistent EP and those with normal contralateral fallopian tubes (P < 0.005). The relative risk of having a clinical pregnancy among those who attempted conception was 2.3 for those having a normal contralateral fallopian tube compared with those with a contralateral fallopian tube with obvious pathology. Intrauterine pregnancy rates after treatment of persistent EP were similar to those reported for primary treatment of EP.

Identifying hearing loss in the intensive care nursery: a 20-year summary

The outcome of a study on hearing loss in graduates of one third-level and two second-level intensive care nurseries (ICN) is reported. The goals were to identify, test, and fit hearing aids on those who need them. Initial hearing-threshold estimates were obtained by auditory brainstem response (ABR) analyses at the time of discharge from the hospital; the mean percentage of failures to respond to 30-dB nHL clicks (in one or both ears) was 19.8 percent for the third-level ICN graduates (N = 4374), and 12.0 percent for the second-level graduates (N = 1527). About half of those with hearing loss at the initial Test were returned for a ReTest 6-20 weeks later, at which time 48.7 percent of the third-level and 44.0 percent of the second-level group were judged normal because they delivered 25-dB click ABRs bilaterally. Following conventional audiological work-ups of the ones with unilateral or bilateral hearing loss, hearing aids were fitted to 92 in the third-level group (2.1% of those Tested) and 22 of the second-level group (1.4%). Not quite half of these fittings occurred within 1 year of the hospital Test that initially diagnosed the loss.

Live birth after treatment of severe adenomyosis with a gonadotropin-releasing hormone agonist

A patient with a 10-year history of secondary infertility underwent GnRH-a therapy with LA for 5 months to control symptoms of severe adenomyosis and to avoid an unwanted hysterectomy. Shortly after cessation of treatment, the patient conceived. A healthy male was delivered at term by cesarean section, which makes this the first report of a live birth after treatment of severe adenomyosis with a GnRH-a.

Reproductive outcome after 143 laparoscopic procedures for ectopic pregnancy

OBJECTIVE

To analyze reproductive outcome after laparoscopic procedures for ectopic pregnancy, with particular attention to laparoscopic salpingectomy.

METHODS

In a 260-physician multispecialty clinic in the rural upper midwestern United States, 143 patients were followed prospectively after undergoing laparoscopic procedures for ectopic pregnancy. Ninety-five who sought further pregnancies during the study period were analyzed for reproductive outcome. Intrauterine pregnancy rates were compared by age, parity, size of ectopic gestation, and evidence of prior tubal damage. Life table analysis was also performed.

RESULTS

The overall intrauterine pregnancy rates for laparoscopic salpingostomy (60%) and laparoscopic salpingectomy (54%) were not significantly different from each other. However, intrauterine pregnancy rates differed significantly by history of prior tubal damage. The pregnancy rate was 79% among women without tubal damage and 42% among women with damage.

CONCLUSIONS

Our intrauterine pregnancy rates after both laparoscopic salpingectomy and laparoscopic salpingostomy are similar to those reported in the literature for similar procedures performed at laparotomy. In predicting pregnancy outcome after laparoscopic procedures for ectopic pregnancy, the major variable seemed to be evidence of prior tubal damage. With no evidence of previous damage, we found similarly high pregnancy rates for laparoscopic salpingostomy and salpingectomy.

Gamete intrafallopian transfer with spinal anesthesia

OBJECTIVE

To investigate the feasibility of performing GIFT under spinal anesthesia administered through a thin (27-gauge) needle.

DESIGN

Prospectively studied case series.

SETTING

A tertiary care center staffed by a 260 physician multispecialty group.

PATIENTS

Twenty-seven consecutive fertility patients underwent 28 laparoscopic GIFT procedures, electing to receive spinal anesthesia administered through a thin (27-gauge) needle.

INTERVENTIONS

Laparoscopic GIFT and thin-needle spinal anesthesia.

MAIN OUTCOME MEASURES

Assessment of anesthetic complications and reproductive outcome.

RESULTS

Satisfactory anesthesia was obtained in 27 of the 28 cases (96%). One patient required additional general anesthesia because of failed spinal anesthesia. All patients were discharged from the hospital on the day of surgery and no postdural headache, persistent back pain, meningitis, or neurological deficit was reported on a 7-day follow-up. Of the 12 clinical pregnancies (43%), 9 ongoing/delivered pregnancies occurred (32%). Six patients had livebirths, and three patients have ongoing second or third trimester pregnancies; there were three spontaneous abortions.

CONCLUSIONS

Spinal anesthesia administered through a 27-gauge needle is an attractive option for laparoscopic GIFT. The risk of serious morbidity because of an anesthetic-related complications may be reduced, and the oocytes are not exposed to the potentially deleterious effects of the drugs associated with general anesthesia.

Laparoscopic diagnosis of puerperal ovarian vein thrombophlebitis. A case report

Puerperal ovarian vein thrombophlebitis is a relatively rare postpartum complication that may result in serious complications. The syndrome may be diagnosed through exploratory surgery or diagnostic imaging, although the best method remains unclear. In one case, open laparoscopy yielded a swift diagnosis and ensured prompt treatment without necessitating further diagnostic studies.

The history and current status of nurse midwifery in Wisconsin

Two editorials in the June 1991 Wisconsin Medical Journal communicated a concern for the equitable provision of health care to all Wisconsin residents. They requested greater commitment to this goal by the state government, and cited quality obstetric care as a worthwhile investment of the public dollar for long-term public health. As part of the discussion of resources available to improve obstetrical care, this paper will present a summary of the current status and potential expansion of midwifery practice in Wisconsin after a synopsis of the relevant historical information.

Laparoscopic treatment of recurrent small bowel obstruction

The treatment of recurrent small bowel obstruction due to postoperative adhesions has traditionally consisted of lysis at laparotomy. We report interval open laparoscopic lysis of adhesions to manage one patient. This technique was safely and effectively applied. Additional cases, however, will need to be analyzed to determine the applicability and indications for a laparoscopic approach to recurrent small bowel obstruction.

Outpatient microsurgical reversal of tubal sterilization by a combined approach of laparoscopy and minilaparotomy

A prospective study of 17 cases of microsurgical reversal of tubal sterilization by a combined approach of laparoscopy and minilaparotomy was performed. Inclusion criteria included age less than 43; weight less than ideal body weight plus 20%; documentation of ovulation; 2 cm of proximal oviduct on hysterosalpingography; and a normal semen analysis or postcoital test. A comparison group of the 5 cases of sterilization reversal performed by a standard inpatient technique during the same period was analyzed. The study technique was performed on an outpatient basis in 15 of the 17 cases, 12 patients (71%) conceived 13 intrauterine pregnancies, one ectopic pregnancy occurred, and total patient costs and time until return to work were significantly less with the study versus standard technique.

Open laparoscopy simplifies instrumentation required for laparoscopic oophorectomy and salpingo-oophorectomy

Eight consecutive cases of open laparoscopic oophorectomy and salpingo-oophorectomy are reported. A modified technique that requires fewer specialized instruments and includes removal of the intact adnexa is demonstrated. Patients were not included if there was any suspicion of malignancy. Indications for surgery included chronic pelvic pain after hysterectomy (N = 5), endometriosis (N = 1), estrogen receptor-positive metastatic breast carcinoma that had not responded to chemotherapy (N = 1), and tuboovarian ectopic pregnancy (N = 1). No intraoperative or postoperative complications occurred. The average hospital stay was 1.1 days, and patients were released 3-14 days postoperatively. Five of the six patients with chronic pelvic pain had prompt resolution of their symptoms. In one patient who had a unilateral salpingo-oophorectomy, a contralateral procedure was required 3 months later because of continued chronic pelvic pain; her pain subsequently resolved. Laparoscopic salpingo-oophorectomy has the potential to decrease morbidity as compared with laparotomy in appropriately selected cases.

Predicting pregnancy outcome by the observation of a gestational sac or of early fetal cardiac motion with transvaginal ultrasonography

Transvaginal ultrasound (US) allows for observation of the gestational sac and cardiac motion as early as 3 and 4 weeks after ovulation, respectively. The purpose of this study was to determine how well the first observation of cardiac motion, using weekly transvaginal US examinations, predicted pregnancy outcome. Three hundred sixteen pregnancies wherein the date of ovulation was known and a single gestational sac was visualized at 3 weeks after ovulation were studied. Cardiac motion was first detected at 4 weeks after ovulation in 226 (71.5%), and at 5 weeks in 67 (21.2%). In 23 patients, cardiac motion was never observed. In those patients with cardiac motion visible at 4 weeks after ovulation, 94.2% have subsequently delivered viable infants. This contrasts with only 70.1% for those patients who first had observable cardiac motion 1 week later (P = 6.7 X 10(-6]. This study demonstrates that the solo finding of a gestational sac is a poor predictor of pregnancy outcome (82.3% accurate) and that the earlier that cardiac motion is initially observed, the better the pregnancy prognosis.

Early crown-rump length. A good predictor of gestational age

With the increased resolution of newer transabdominal and transvaginal imaging equipment, ultrasound is being used more frequently for the diagnosis of early pregnancy complications. Extrapolation of gestational age from early crown-rump lengths (CRLs) has been difficult because previously established tables of CRL versus gestational age have contained few measurements at less than seven to eight weeks from the first day of the last menses. Accordingly, the relationship between early CRL (in millimeters) and calculated menstrual age (CMA) (in days) in 36 patients with a known date of conception was studied with transvaginal sonography and found to have a linear relationship, defined by the equation CMA = 0.99 x CRL + 40.0 (r = .95, P less than .001). The relationship can be used to date pregnancies as early as 26 days after conception.

Intrauterine insemination of cryopreserved donor semen

The use of cryopreserved specimens is becoming the standard of care for donor insemination. Commercial specimens often have low numbers of actively motile sperm. Intrauterine insemination may be of value in the wives of men with oligoasthenospermia. Accordingly, an intrauterine insemination protocol using one or two vials of commercial semen with a minimum of 24 million motile sperm per vial was used to determine if acceptable monthly conception rates could be obtained. During the study period, there were 82 insemination cycles, resulting in 20 pregnancies in 35 women. The monthly conception rate was 24% and monthly ongoing pregnancy rate was 18%. If confirmed by other investigators, intrauterine insemination may be a way to improve the pregnancy rate with cryopreserved semen.

Intraoperative rapid autologous blood transfusion

Intraoperative rapid autologous blood transfusion is a resource that is available in many operating suites but is currently underused in gynecologic surgery. A case is presented in which an intraoperative autotransfusion of 1560 ml of free intraperitoneal blood was performed to aid in resuscitation of a 31-year-old woman with a ruptured tubal pregnancy.

Management of unruptured ectopic gestation by linear salpingostomy: a prospective, randomized clinical trial of laparoscopy versus laparotomy

This study was designed to compare prospectively the parameters of morbidity, cost, length of hospital stay, and fertility outcome after linear salpingostomy by laparoscopy versus laparotomy. Entry criteria included stable vital signs, hematocrit greater than 30%, age over 18 years, and desire for future fertility. All patients underwent diagnostic laparoscopy. Sixty patients with unruptured ectopic gestations of 5 cm or smaller were randomized to either laparoscopy (N = 30) or laparotomy (N = 30). Postoperative follow-up included serial measurements of serum beta-hCG titers at 3-day intervals and hysterosalpingography at 12 weeks. The laparoscopy and laparotomy groups were similar in age, height, weight, gravidity, gestational age, hematocrit, ectopic pregnancy size, and preoperative beta-hCG levels. The estimated blood loss was significantly (P less than .001) lower in patients undergoing laparoscopy, and was not affected by vasopressin injection. Two patients in the laparoscopy group required laparotomy for hemostasis, and two patients undergoing laparotomy had wound infection. One patient in each group had persistent trophoblastic activity. Baseline serum beta-hCG levels and the rate and magnitude of postoperative beta-hCG decline were similar in both groups. The length of hospital stay was significantly (P less than .001) shorter after laparoscopic salpingostomy (1.4 +/- 0.1 days) than after laparotomy (3.3 +/- 0.2 days). Postoperative hysterosalpingography showed patency of the involved tube in 16 of 20 (80%) and 17 of 19 (89%) of patients in the laparoscopy and laparotomy groups, respectively. Pregnancy rates were ten of 18 (56%) and 11 of 19 (58%) in these groups, respectively, and all pregnancies were conceived within 6 months of surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Gonadal function and ovarian galactose metabolism in classic galactosemia

Evaluation of ovarian steroid secretion, histologic examination of ovarian tissue, and incubation studies with radiolabelled galactose in ovarian tissue slices were performed in a 21-year-old woman with galactosemia and incipient ovarian failure. After exogenous gonadotropin administration in an attempt to achieve fertility, there was no evidence of ovulation by ultrasound; estrogen and androgen production were deficient indicating ovarian unresponsiveness. Histologic examination of the ovary revealed that the ovarian stroma had an increase in fibrous tissue and that a few hyalinized atretic follicles were present with no intermediate or evolving Graafian follicles. After incubation with galactose-1-14C, there was absence of labelled CO2 production and only labelled galactose-1-phosphate was identified as compared to controls in which several labelled intermediates could be seen. The incorporation of galactose into the TCA-insoluble fraction was drastically reduced in the patient compared to controls, suggesting that there may be a deficiency of ovarian galactose-containing glycolipids, glycoproteins and mucopolysaccharides in the galactosemic ovary. Deficiency in the production of galactose containing compounds, or galactose-1-phosphate accumulation or both, may lead to the development of hypergonadotropic hypogonadism seen in women with galactosemia.

Persistent tubal ectopic gestation: patterns of circulating beta-human chorionic gonadotropin and progesterone, and management options

To aid in the clinical decision making involved with persistent ectopic gestation, a total of 329 operative procedures for tubal gestation were reviewed. Six of 114 (5.3%) cases treated conservatively had persistent trophoblastic activity. The decline in serum beta-human chorionic gonadotropin (hCG) and progesterone (P) at 3 and 6 days postoperatively was similar in the "persistent ectopic" and the "resolved ectopic" groups. However, beyond day 6 both beta-hCG percentage of baseline and P level were significantly higher in the "persistent ectopic" (greater than 22.6 +/- 6.6%, greater than 3.4 +/- 0.7 ng/ml, respectively) than the "resolved ectopic" group (less than 2.7 +/- 0.8%, less than 0.2 +/- 0.05 ng/ml, respectively). Four patients underwent a second operation, whereas two were managed expectantly. These data suggest that the diagnosis of persistent ectopic gestation is best made by an initial measurement of serum beta-hCG or P at 6 days postoperatively, and at 3 day intervals thereafter. The choice of management may be determined by various factors including serum beta-hCG and patient's symptoms.

Diagnosis and management of a tuberculous, tuboappendiceal fistula

A tuberculous tuboappendiceal fistula was demonstrated on a hysterosalpingogram in an asymptomatic patient being evaluated for infertility. Antituberculous medical treatment resulted in closure of the fistula.

Clinical and ultrastructural findings of an androgenizing Krukenberg tumor in pregnancy

A clinical and ultrastructural study of an androgenizing Krukenberg tumor in pregnancy is presented. Ultrastructural observations suggested the abundant, hyperplastic, luteinized ovarian interstitial cells as the probable cause of elevated circulating levels of testosterone (5400 ng/dL). The unusual fine structure of these cells, which included large intramitochondrial lipid droplets and abundant smooth endoplasmic reticulum, was indistinguishable from that reported to occur in Leydig cells stimulated by exogenous gonadotropins.

Effect of androgen on adrenal steroidogenesis in normal women

Ovarian hyperandrogenism may induce adrenal enzymatic defects that mimic true inherited disorders of adrenal hormone biosynthesis. To assess the effect of hyperandrogenism on adrenal steroidogenesis, seven normal ovulatory women were studied on 2 days during the early follicular phase of their cycles. Plasma 17-hydroxyprogesterone (17-Prog), 17-hydroxypregnenolone, dehydroepiandrosterone (DHEA), DHEA sulfate, androstenedione (Adione), testosterone (T), 11-deoxycortisol, and cortisol concentrations were measured every 15 min for 3 h after iv injection of 0.25 mg ACTH (day 1) and pretreatment with dexamethasone on each day. On the second study day, T (80 micrograms/h) was infused iv for 5 h, and ACTH was given after 2 h of T infusion. The T infusion raised mean serum T levels from 1.2 +/- 0.3 (+/- SE) to 8.6 +/- 0.6 nmol/L. The maximum incremental (delta max) plasma Adione response to ACTH was significantly higher (2.6 +/- 0.3 to 3.2 +/- 0.4 nmol/L; P less than 0.009) during the T infusion, while the delta max responses of the other steroids did not change. There was an increase in the delta max 17-Prog to cortisol ratio (4.9 +/- 0.7 to 7.0 +/- 1.0; P less than 0.05), but no change in the delta max 17-Prog to Adione or 17-hydroxypregnenolone to DHEA ratios and no changes in the delta max delta 5- to delta 4-steroid ratios. These data suggest that acute T elevations result in subtle inhibition of 21-and/or 11 beta-hydroxylase activities, but not in 17-20-desmolase or 3 beta-ol activities.

Endogenous opioids modulate the inhibitory effects of androgen on the hypothalamic-pituitary axis of normal women

This study was designed to investigate the effect of dihydrotestosterone (DHT) on LH secretion in normal women and the role of endogenous opioids in modulating this effect. Pulsatile LH release and maximum LH responsiveness to exogenous GnRH were determined on 3 consecutive days: basally (day 1), during DHT infusion (day 2), and during DHT plus naloxone (Nal) infusion (day 3). Steady state plasma DHT levels of 6.5 +/- 1.1 (+/- SEM) ng/mL (22.5 +/- 3.8 nmol/L) were achieved by infusion. DHT infusion significantly decreased the maximum LH response to GnRH from 35.5 +/- 8.2 to 11.6 +/- 2.8 IU/L (P less than 0.05). This inhibitory effect was not altered by Nal. In addition, DHT significantly decreased LH pulse frequency (basal, 4.3 +/- 0.3; DHT, 2.8 +/- 0.3 pulses/6 h; P less than 0.05), but not the amplitude of the LH pulses. However, after the addition of Nal to DHT, the pulse frequency increased significantly from 2.8 +/- 0.3 to 4.7 +/- 0.3 pulses/6 h (P less than 0.05). The mean plasma LH level did not change during the infusion of DHT alone, but it did increase significantly when Nal was added (DHT, 4.8 +/- 1.0; DHT + Nal, 7.9 +/- 1.0 IU/L; P less than 0.01). The results of this acute pharmacological study suggest that androgens may have two separate effects on the hypothalamic-pituitary axis: 1) inhibition of GnRH release, which appears to be mediated via opioid peptides, and 2) inhibition of pituitary LH secretion, which is not dependent on opioids.

Androstenedione may be a more important precursor of tissue dihydrotestosterone than testosterone in women

The expression of androgenic features in the external genitalia and skin is largely dependent on the intracellular formation of dihydrotestosterone (DHT). The relative contributions of androstenedione (delta 4A) and testosterone (T) to DHT production in skin have not been compared. To clarify this, the authors studied the in vitro conversion of delta 4A to DHT, delta 4A to T, and T to DHT in genital and/or pubic skin minces from 20 normal women, 4 hirsute women, and 3 normal men. In normal women, the mean conversion ratios (CRs) of delta 4A to DHT in genital skin (7.06% +/- 1.72%, standard error of the mean) and in pubic skin (2.30% +/- 0.26%) were both significantly higher (P less than 0.05) than the respective mean CRs for T to DHT in genital and pubic skin (3.53% +/- 0.68% and 0.74% +/- 0.14%). In hirsute patients, the data suggested a higher CR of delta 4A to DHT (10.6% +/- 4.59%) compared with T to DHT (4.17 +/- 1.07). Conversely, the CR of delta 4A to DHT (12.8% +/- 9.8%) was significantly lower than the CR of T to DHT (59.7% +/- 12.0%) in male genital skin (P less than 0.01). Since daily blood production rates and serum concentrations of delta 4A are higher than T in women, it is concluded that delta 4A may be a more important precursor for DHT in female skin.

Ectopic pregnancy in unrepaired distal tubal remnant after contralateral tubal anastomosis

A case is described in which, after a tubal sterilization procedure and subsequent unilateral tubal anastomosis, an ectopic gestation occurred in the contralateral, unrepaired, distal tubal segment. On the basis of this case and related evidence, the authors suggest that in cases in which only a unilateral tubal anastomosis is possible, strong consideration should be given to removal of the contralateral, unrepaired, distal tubal remnant.

Abnormal fetal heart rate pattern associated with severe intrapartum maternal ethanol intoxication. A case report

Acute intrapartum ethanol intoxication occurred in a chronic ethanol abuser. Continuous fetal heart rate monitoring revealed a pattern of fetal tachycardia, decreased variability and late and variable decelerations in association with a maternal serum ethanol level of 300 mg/dL. This case gives evidence of an association between very high maternal serum ethanol levels and acute fetal distress.

Oviductal cilial phagocytosis in patients undergoing tubal reanastomosis

Chronic salpingitis has been reported in patients undergoing reversal of sterilization. For investigation of a possible microbial etiology for this process and characterization of its ultrastructural features, segments from the midportion of the fallopian tubes of five patients who underwent sterilization reversal were studied by comprehensive tubal cultures, and light and electron microscopy. Three patients undergoing sterilization by partial salpingectomy were studied as controls. Chlamydial IgG and IgM antibody titers were performed on serum samples. No microbiologic or serologic evidence for active infection by known pathogens was found. In three of the study patients mild oviductal mural fibrosis was present. However, in two other study patients chronic salpingitis with phagocytosis of cilia by luminal macrophages was demonstrated. It is suggested that if this active process persists after tubal reanastomosis, it may result in impaired oviductal function.