Failed instrumental delivery: how safe is the use of a second instrument?

An audit of failed instrumental deliveries was undertaken to assess the incidence of complications and the adequacy of documentation. When one instrument has failed to effect delivery, the use of a second instrument could in most cases be used to complete the delivery without harm to the mother or baby. However in a small but significant number of cases there are severe maternal or perinatal complications, and these could be the subject of litigation. This could be avoided by adequate pre-application assessment, standard conduct of instrumental delivery and full documentation. Inadequate documentation could be overcome by the use of a pro forma. Selective use of plastic and metal cups could reduce the incidence of failed attempts.

Loop diathermy excision compared with cervical laser vaporisation for the treatment of intraepithelial neoplasia: a randomised controlled trial

OBJECTIVE

To determine whether loop diathermy excision of the transformation zone and laser vaporisation are equally effective in the treatment of cervical intraepithelial neoplasia.

DESIGN

Randomised controlled trial.

POPULATION

Women referred for evaluation of cytological abnormality who were considered suitable for outpatient local destructive treatment.

SETTING

Seven colposcopy units in the North West Region.

METHODS

Loop diathermy excision of the transformation zone and laser vaporisation.

MAIN OUTCOME MEASURE

Smear reported as moderate dyskariosis or worse following treatment.

RESULTS

Of 289 women randomised, 285 had one or more smears following treatment. Women were more likely to have a smear reported as moderate dyskariosis or worse following laser vaporisation [hazard ratio 3.01 (95% CI 1.27 to 7.12)]. The cumulative risk of a smear reported as moderate dyskariosis or worse was 6.0% at six months and 12.1% at three years in those allocated laser vaporisation, and 2.0% at six months, and 3.3% at three years in those allocated loop diathermy excision of the transformation zone.

CONCLUSIONS

Loop diathermy excision is a more effective treatment of cervical intraepithelial neoplasia than laser vaporisation.

Diagnostic lessons of mucosal melanoma with osteocartilaginous differentiation

AIMS

To document the clinical, morphological and immunohistochemical features of two cases of primary mucosal melanoma with osteocartilaginous differentiation.

MATERIALS AND METHODS

Two cases of mucosal melanoma with cartilage and bone formation are reported, one arising in the vagina of a 79-year-old woman and one in the oral cavity of a 67-year-old man. The vaginal melanoma exhibited only cartilaginous differentiation. The oral cavity mucosal melanoma exhibited both bone and cartilage formation and was remarkable for its multifocality, long history not associated with metastases and its lengthy manifestation of dual morphologies: some of the tumours were typical in situ/invasive melanotic melanomas whilst the others were composed of amelanotic spindle and epithelioid cells with osteocartilaginous tissue. One of the lesions exhibited in situ and invasive melanoma with transition to an osteogenic tumour in places. The patient also developed nonosteogenic malignant melanomas in the nasal cavity and nasopharynx.

CONCLUSIONS

Malignant melanomas showing foci of osteocartilaginous differentiation are extremely rare with only 18 cases reported. Primary mucosal malignant melanomas of vagina and oral cavity showing osteocartilaginous differentiation have not previously been documented. Primary vaginal melanoma with cartilaginous differentiation must be distinguished from primary malignant mixed Müllerian tumour whilst malignant change in a pleomorphic adenoma, sarcomatoid carcinoma, osteogenic sarcoma and mesenchymal chondrosarcoma are included in the differential diagnosis of primary oral mucosal melanomas with osteocartilaginous differentiation. In this context, immunohistochemistry using antibodies to cytokeratin, S100 protein and MIC2 is of value.

Post-operative spindle cell nodule of the vulva

A case of post-operative spindle cell nodule arising in the vulva of a 33-year old woman is reported and the relevant literature reviewed. This is an uncommon, benign lesion which develops soon after a surgical procedure and which is composed of mitotically active spindle cells, causing possible confusion with sarcoma. Knowledge of the clinical history and an awareness of the existence of such lesions is necessary in order to avoid misinterpretation.

Recreational sports and the weekend athlete

It is important to design an exercise program that provides an adequate amount of activity to attain maximal benefits at the lowest risk to the participant. Permanent lifestyle changes in eating and activity habits should be included in the primary goals of all programs.

Postoperative necrotising granulomata in the cervix and ovary

Images

The computer. An orthopedic instrument

The computer has become an important tool in orthopedic practice. Indeed, it is now invaluable and will soon be essential. It is still possible to run an orthopedic office without a computer--just as it is still possible to perform meniscectomy by arthrotomy--but that is not what most of us would do. The computer enhances efficiency, can improve business practice, assists in marketing, and helps store and retrieve medical information. The ultimate impact is not only on "business" functions but also on the quality of care.

Whiplash syndrome. Fact or fiction?

A sprain/strain syndrome or "whiplash injury" is the most common cervical injury associated with rear-end impact motor vehicle accidents. This results in a complex injury, often associated with extensive soft tissue injury in the cervical spine. There is additional potential for long term alteration in neurologic, muscular, and skeletal function. Evaluation and treatment should follow standard orthopedic principles.

Fixed minidose warfarin: a new approach to prophylaxis against venous thrombosis after major surgery

A prospective study was carried out to see whether a small fixed dose of warfarin (1 mg daily) given before operation (mean 20 days) would prevent deep vein thrombosis in patients having major gynaecological surgery. One hundred and four patients were randomised into three groups: fixed minidose warfarin; full dose oral anticoagulation; and no treatment (controls). There was a significantly lower incidence of deep vein thrombosis in the minidose warfarin and full dose anticoagulant treatment groups (9% (3/32) and 3% (1/35) respectively) than in the controls (30%; 11/37) but no significant difference between the two anticoagulant treatment groups. Prothrombin time and the activated partial thromboplastin time were normal on the day of surgery in the warfarin treatment group, whereas times were prolonged in the group given full dose anticoagulation. Mean haemoglobin concentrations fell in all three groups after operation but the fall was significantly less in the minidose warfarin treatment group than after full dose anticoagulation. The benefit from full dose oral anticoagulant prophylaxis, based on a preoperative international normalised ratio of 1.5-2.5 with rabbit brain Manchester reagent, was similar to the protection achieved in an oral anticoagulant treatment group controlled with human brain Manchester comparative reagent at a similar level of anticoagulation. The lack of disturbance of normal haemostasis at the time of operation together with a significant reduction in deep vein thrombosis may encourage surgeons to introduce minidose prophylaxis with warfarin.

Acute epiglottitis in adults. An eight-year experience in the state of Rhode Island

We retrospectively reviewed the medical records on all cases of acute epiglottitis in adults from each of the hospitals in Rhode Island and from the state medical examiner's office over an eight-year period (1975-1982). We found 56 cases--an annual incidence of 9.7 cases per million adults. A significant increase occurred in the last two study years. Indirect laryngoscopy proved to be more reliable in making a diagnosis than did x-ray films of the neck; all of 41 indirect examinations were performed without complications. Twenty-three percent (6 of 26) of patients in whom blood cultures had been obtained had bacteremia, all with Hemophilus influenzae. Bacteremia was associated with a high risk of airway obstruction. Four patients died, all from acute airway obstruction, for a mortality rate of 7.1 percent--a rate significantly higher than the current rate among children. Two deaths occurred after admission, while the patients were being observed without an artificial airway. We conclude that the incidence of epiglottitis in adults is higher than previously believed and may be increasing. Fatal airway obstruction can occur without warning, indicating a need for early protection of the airway in adults as well as in children.

Musculoskeletal problems in hemophilia

Spontaneous deep muscle and joint bleeding is a common characteristic of severe hemophilia, often causing damage to the musculoskeletal system. The development of concentrated replacement factors, however, has made home care programs possible, helped prevent deformity, and improved surgical management.

Hip dysplasia in infancy. Diagnosis and treatment

Diagnosis of hip dysplasia in the newborn is entirely by physical examination. In older infants, however, x-ray examination is valuable in confirming the diagnosis. The Pavlik harness is recommended as a safe, simple, and effective method of treatment; but no matter which device is preferred, once hip dysplasia is suspected, treatment should begin immediately.

Normal human endometrium in cell culture. I. Separation and characterization of epithelial and stromal components in vitro

Separation of human endometrium into its epithelial and stromal components has been achieved through collagenase digestion and has permitted a study of these two cell populations under specific experimental culture conditions. The stromal cell populations showed a progesterone response, were easily handled in culture, and displayed a limited in vitro life span typical of human diploid fibroblasts. In contrast, epithelium only survived in short-term primary culture and showed no clear hormone response. High-density epithelial cultures remained viable for longer periods in culture. Comparisons between resurfacing endometrial epithelial cells in vivo and epithelial cells migrating from explants in vitro suggested that this initial epithelial migration in vitro was the counterpart of the repair response in vivo.

Haematological indices of the mother and baby during labour

Haematological indices were obtained by Coulter Counter analysis from 325 women in the first stage of labour, and from the cord blood of their newborn babies. The mean maternal haemoglobin concentration was 12.49 g/dl and the mean cord haemoglobin 16.18 g/dl. The mean corpuscular volume measured directly was 89.00 fl from maternal blood and 106.73 fl from the cord blood; the two ranges barely overlapped and it should be possible by automated analysis to differentiate between fetal and maternal blood obtained at amniocentesis or artificial rupture of the membranes at term.