Analysis of the sonographic predictors of difficult laparoscopic cholecystectomy in symptomatic cholelithiasis

BACKGROUND

Laparoscopic cholecystectomy (LC) is one of the most common laparoscopic procedures performed by young surgeons nowadays. Sometimes, LC could be challenging, especially for junior surgeons leading to serious complications. Therefore, this study aims to investigate the preoperative ultrasonographic features that could predict difficult LC.

METHODS

In this prospective study, patients (n = 204) who underwent LC for symptomatic cholelithiasis from January 2020 to August 2022 were included. Preoperative parameters, including the ultrasonographic findings, were evaluated for their ability to predict difficult LC.

RESULTS

The difficulty of LC was evaluated using two intraoperative scores. Among the ultrasonic parameters that were assessed preoperatively, thickened gallbladder (GB) wall, contracted GB, and impacted stone in the GB neck were associated with difficult LC. However, an impacted stone in the GB neck was the only independent predictor of difficult LC according to both difficulty scores in the multivariate analysis (odds ratio [OR] = 7.56, p = .001; OR = 8.42, p = .001).

CONCLUSIONS

The impacted stone in the GB neck is an ultrasonographic sign of difficult LC. It should alert the surgeon for a more appropriate preoperative preparation, and the patient should be informed about the increased risk of complications, including conversion to open cholecystectomy.

D-line Approach for Safe Laparoscopic Cholecystectomy: Initial Experience

Introduction The critical view of safety is an important concept for safe laparoscopic cholecystectomy. However, no standard step-by-step approach for achieving the critical view of safety has been established until now. Therefore, this study aims to evaluate a new approach for achieving the critical view of safety using the diagonal line of liver segment IV as an anatomical landmark. Patients and methods In this prospective non-randomized study, patients (n= 112) who underwent laparoscopic cholecystectomy for symptomatic cholelithiasis were included. The first 47 patients underwent laparoscopic cholecystectomy using the diagonal line approach (DLC group) whereas, the next 65 patients underwent laparoscopic cholecystectomy using the conventional method (CLC group).  Results No significant difference between both groups regarding the preoperative characteristics, operative time, and intraoperative blood loss. Laparoscopic subtotal cholecystectomy was performed more in the DLC group (6% vs 0%, p= 0.07). Whereas, in the CLC group, there was a tendency towards conversion to open cholecystectomy in difficult cases (6% vs 2%, p= 0.40). No intra- or postoperative complications occurred in either group.  Conclusion The diagonal line approach is a feasible and useful step-by-step technique to achieve the critical view of safety in laparoscopic cholecystectomy and enables surgeons to perform safe laparoscopic subtotal cholecystectomy in difficult cases.

Watchful waiting for communicating hydrocoele in infants

Background

One of the commonest pediatric surgeries is hydrocele. There are suggestions to wait for spontaneous resolution than to operate these cases without harmful adverse events. Herein, we evaluated the outcome of the watchfulness of these cases over 18 months.

Methods

The study included 93 infants with communicating hydrocele for the Pediatric Surgery Department, Faculty of Medicine (Assiut, Egypt). They were planned to be followed up for 18 months, and indications for intervention included hernia, increasing in size, being tense, and completion of 18 months of follow-up without improvement.

Results

The gestational age of the included patients was 38.5 ± 2.2 weeks and the age at the time of presentation was 50 (7, 495) days. Most cases were bilateral, reducible, and had an intermittent course. After 18 months of follow-up, 60.2% of the patients resolved spontaneously and 39.8% were surgically treated. Age at the time of presentation was higher among operated patients. Patients with reducibility criteria on clinical examination and lack of intermittent course had higher frequency among operated patients (89.2%).

Conclusions

It is safe to wait and not to operate on infants with hydrocele up to 18 months as long as there was no hernia. Higher age at presentation and reducibility on examination are indicators that favor the need for surgery.

Predictors of portal vein complications after pediatric liver transplantation: A German center experience

BACKGROUND

Portal vein complications (PVCs) after pediatric liver transplantation (LT) are sometimes asymptomatic, especially in the early phase, and can threaten both the graft and patient's survival. Therefore, the purpose of this study is to analyze the risk factors for portal vein thrombosis (PVT) and portal vein stenosis (PVS) after pediatric LT.

METHODS

All pediatric patients (n = 115) who underwent primary LT at Regensburg University Hospital between January 2010 and April 2017 were included in this study. The pre-, intra-, and postoperative parameters of all patients were retrospectively reviewed and risk factors for both PVT and PVS were analyzed.

RESULTS

Of the 115 patients, living donor LT was performed on 57 (49.5%) patients, and biliary atresia was the primary diagnosis in 65 patients (56%). After pediatric LT, 9% of patients developed PVT, and 16.5% developed PVS. Patient weight ≤7 kg [odds ratio (OR) 9.35, 95% confidence interval (CI) 1.03-84.9, p = .04] and GRWR >3% (OR 15.4, 95% CI 1.98-129.5, p = .01) were the independent risk factors for the development of PVT and PVS, respectively upon multivariate analysis. The overall patient survival rates at 1, 3, and 5 years were 91%, 90%, and 89%, respectively, and there was no difference in patient survival among those with and without PVCs.

CONCLUSIONS

Pediatric patients with body weight <7 kg and/or receiving a graft with GRWR >3% may develop PVCs and so require certain surgical modifications, close follow-up, and prophylactic anticoagulant therapy following transplant.

Splenic auto-transplantation after splenectomy for trauma: evaluation of a new technique

BACKGROUND

Splenic autotransplantation is a promising method to recover splenic functions after traumatic splenectomy. However, it is associated with several postoperative complications, such as subphrenic abscess, intestinal obstruction and torsion of the omentum with necrosis of the implanted splenic tissues. Therefore, the aim of this study is to evaluate a new splenic autotransplantation technique that could overcome those complications.

MATERIALS AND METHODS

A single segment of the spleen was implanted inside a pedunculated omental pouch and fixed in the native site of the spleen in 15 patients who underwent splenectomy for abdominal trauma. This group of patients was compared with the next 17 patients who underwent splenectomy alone. Additionally, splenic functions of the patient and control groups were evaluated 3 months using peripheral blood smear [the presence of Howell-Jolly (HJ) bodies] and abdominal contrast-enhanced computed tomography (CECT).

RESULTS

All patients who underwent splenic autotransplantation showed evidence of a well-vascularised splenic tissue on CECT and normal peripheral blood smear without HJ bodies 3 months postoperatively. No postoperative complications related to splenic autotransplantation were observed, and platelet count after 3 months was significantly higher in patients who underwent splenectomy only (p = 0.04).

CONCLUSIONS

Splenic autotransplantation using the aforementioned technique could restore splenic functions with minimum postoperative complications related to the procedure.

1430 Mid-Term Outcomes After Endovascular Repair of Popliteal Artery Aneurysms Demonstrate Satisfactory Patency Rates and Safety of Stent-Grafts

Aim

Popliteal artery aneurysms (PAAs) are increasingly treated via an endovascular approach. We present mid-term outcomes of popliteal endovascular aneurysm repair (PEVAR) from a single centre.

Method

A retrospective analysis of a prospective database of consecutive patients who underwent either elective or emergency PEVAR in a single regional vascular centre from January 2010 to August 2020. The patients underwent placement of a heparin-bonded stent-graft (Viabahn Endoprosthesis, WL Gore and Associates, Flagstaff, USA) for PAA &gt;20mm or complications: thromboembolism, rupture or popliteal vein thrombosis. Patency and stent-graft related complications were assessed.

Results

A total of 64 PAAs (mean size 36.8±13.4mm) were treated in 56 patients (mean age 75±10.7 years, 54 (96%) male). Median follow-up was 29.5 months (IQR 36.75). 30-day mortality was 0%. Technical success rate of stent-graft insertion was 100%. 1-year and 5-year primary patency was 83% and 67% respectively; primary-assisted patency at these time points was 86% and 72%, and the corresponding secondary patency was 89% and 75%. 61 out of 64 treated limbs had &gt;1 vessel runoff. The most frequently occurring complication was stent-graft occlusion which affected 11 (17%) limbs. Stent-graft fracture occurred in 1 patient, resulting in endoleak.

Conclusions

Viabahn Endoprosthesis can be used successfully in treatment of PAA with acceptable short- and mid-term patency rates. One in five patients in this cohort required a reintervention, with most complications occurring in the first year postoperatively. Stent-graft fracture occurred only in one patient demonstrating that PEVAR is a safe option for PAA management in the intermediate term.

Different clinical risk scores for prediction of early mortality after liver resection for hepatocellular carcinoma: which is the best?

BACKGROUND

Prediction of early mortality after hepatectomies for hepatocellular carcinoma is essential to identify high-risk patients and to decrease the operative mortality rate. Several post-operative clinical risk scores were developed recently to predict mortality post-hepatectomy; however, which one is the best remains undefined. Therefore, the aim of this study was to evaluate the performance of the different post-operative clinical risk scores in predicting early mortality after hepatectomies.

METHODS

A total of 240 patients who underwent liver resection for hepatocellular carcinoma at our hospital between June 2011 and July 2016 were retrospectively reviewed. Post-operative clinical risk scores including 50-50 criteria, peak bilirubin >7 mg/dL, model for end-stage liver disease (MELD), risk assessment for early mortality and Hyder scores were evaluated for their performance in predicting early mortality after hepatic resection using the receiver operating characteristic (ROC) curve.

RESULTS

The 90-day mortality rate after hepatic resection was around 2.5%. The 50-50 criteria and peak bilirubin >7 mg/dL were weak predictors of early mortality with low sensitivity (area under the ROC curve: 0.65, 0.66, respectively), whereas, Hyder, risk assessment for early mortality, and post-operative MELD were good predictors of early mortality (area under the ROC curve: 0.89, 0.91 and 0.88, respectively). Moreover, MELD score on post-operative day 3 was an independent risk factor for 90-day mortality with an odds ratio of 1.4 (95% confidence interval 1.06-1.81, P = 0.02).

CONCLUSIONS

Post-operative clinical risk scores, especially MELD, were capable of predicting early mortality after liver resection and should be used to identify high-risk patients and provide them with more intensive medical care.

Henoch-Schönlein Purpura After Living Donor Liver Transplantation: Report of the First Case

Henoch-Schönlein purpura (HSP) is a systemic vasculitis affecting the small vessels that mainly presents in children and young adults. It is characterized by tissue deposition of immunoglobulin A (IgA) immune complexes with the classic manifestations of purpura, arthritis, arthralgia, and gastrointestinal and renal involvements. We report a case of HSP nephritis that occurred 2 years after living-donor liver transplantation (LDLT). After pulse steroid administration, the patient's symptoms disappeared and blood markers normalized. To the best of our knowledge, this is the first HSP case to be reported in a liver transplant recipient.

Evans Syndrome After Successful Immunosuppressant-Free Living-Donor Liver Transplant

Evans syndrome is an uncommon disease characterized by a combination of autoimmune hemolytic anemia and autoimmune thrombocytopenia concomitantly or sequentially with a positive direct Coombs test in the absence of any underlying known cause. Here, we present a case of an adult patient who underwent living-donor liver transplant that was preceded by bone marrow transplant 20 years earlier from the same HLA identical donor and who received a single-agent immunosuppressive therapy for only 2 months as prophylaxis against graft-versus-host disease. Two months after transplant, he developed Evans syndrome with severe anemia and thrombocytopenia. After administration of steroids and intravenous immunoglobulin, the patient's anemia and thrombocytopenia improved dramatically. Through the 7 years of follow-up, the patient has not developed graft-versus-host disease or acute or chronic rejection. This case demonstrates a rare complication posttransplant and the possibility of functional tolerance of liver grafts after a combined liver and bone marrow transplant from the same donor.

Is Muscle MELD a More Promising Predictor for Mortality After Living Donor Liver Transplantation?

BACKGROUND

To improve the outcome of living donor liver transplantation (LDLT), a scoring system that could predict accurately the patient and graft survival posttransplant is necessary. The aim of this study is to evaluate our previously proposed Muscle-model for end-stage liver disease (M-MELD) score and to compare it with the other available scores to find the best system that correlates with postoperative outcome after liver transplant.

METHODS

We retrospectively reviewed the data of 199 patients who underwent LDLT from January 2010 to July 2016 and calculated the preoperative MELD, MELD Na, the product of donor age and MELD (D-MELD), M-MELD, integrated MELD, and the balance of risk (BAR) score in all patients. The area under the receiver operating characteristics curves (AUCs) of each score was computed and compared at 3-, 6-months, and 1-year after LDLT.

RESULTS

The M-MELD, D-MELD, and integrated MELD had a good discriminative performance in predicting 3-month mortality after LDLT with AUCs > 0.7, while the M-MELD was the only score that showed a good discriminative performance in predicting 6-month and 1-year mortality after LDLT with AUCs > 0.7.

CONCLUSION

Muscle-MELD score is a simple and useful predictor of patient survival after LDLT which showed a better predictive performance than other available scores.

Sclerosing encapsulating peritonitis after living-donor liver transplantation: A case series, Kyoto experience

Sclerosing encapsulating peritonitis (SEP), or abdominal cocoon is a rare cause of intestinal obstruction, and still etiology remains unknown. We report a series of 4 patients with abdominal cocoon, and all the 4 patients had previously undergone living-donor liver transplantation (LDLT). There was no evidence of SEP before and during LDLT. At the time of diagnosis of SEP, 3 out of 4 patients had ascites. First and fourth patients had multiple episodes or attacks of cholangitis, which were managed by percutaneous transhepatic biliary drainage and hepaticojejunostomy, respectively. All 4 patients presented with intestinal obstruction and 3 of them underwent a successful operation. The fourth patient died due to liver failure and complications of the SEP. The first 3 patients are doing well without SEP recurrence. Our experience suggest that the prognosis of SEP is poor in patients with poor graft liver functions after LDLT.

The Impact of Preoperative Hemoglobin Level on the Short-Term Outcomes After Living Donor Liver Transplantation

BACKGROUND

Preoperative anemia was reportedly associated with increased morbidity and mortality after various types of surgeries. However, its impact on the outcomes after liver transplantation has not been thoroughly investigated.

METHODS

We retrospectively investigated the clinical outcome of 216 consecutive adult patients who underwent living donor liver transplantation at our institute between January 2010 and June 2017 and stratified them according to the hemoglobin level before transplant. Risk factors for 90-day patient mortality, especially infection-related mortality and early graft loss, were evaluated.

RESULTS

We found that patients with preoperative hemoglobin below 10 g/dl required more intraoperative packed red blood cell transfusions (p = 0.002) and had significantly higher early 90-day postoperative mortality rate (p = 0.007), particularly infection-related mortality (p = 0.002), lower overall graft, and patient survival rates (p = 0.007, p = 0.013, respectively). Preoperative hemoglobin below 10 g/dl was an independent risk factor for increased post-transplant 90-day patient mortality (OR 2.92, p = 0.02), infection-related mortality (OR 6.81, p = 0.02), and early graft loss (OR 3.26, p = 0.01).

CONCLUSION

Preoperative hemoglobin level below 10 g/dl is associated with poorer short-term outcomes after liver transplantation and should be corrected preoperatively if possible through safe and effective treatment modalities.

Evaluation of a new energy device for parenchymal transection in laparoscopic liver resection

INTRODUCTION

THUNDERBEAT (TB) is a novel device that uses both ultrasonic and advanced bipolar energies for hemostasis. Several recent human studies have proved the safety and efficacy of TB in different surgical procedures, but there have been no similar studies about its efficacy in hepatic parenchymal transection. Therefore, the aim of the study was to assess the safety and efficacy of the TB device in laparoscopic liver resection.

METHODS

This retrospective study compared TB and ultrasonic Harmonic devices in 80 patients who underwent laparoscopic liver resection from 2010 to 2016 in our institution. To reduce the selection bias, the two groups were matched in a 1-to-2 ratio on the basis of propensity scores.

RESULTS

There were no differences in the preoperative patient characteristics between the two groups. The extent of liver resection was comparable between the groups. Although the Harmonic group's intraoperative blood loss and operative time were less than that of the TB group, the differences were not statistically significant (P = 0.08, P = 0.32, respectively). Postoperative complications, mortality within 90 days, and hospital stay were comparable between the two groups.

CONCLUSION

TB is as safe and effective for parenchymal transection in laparoscopic hepatectomy as ultrasonic devices, but it is not a superior alternative.

A Propensity Score-Based Analysis of Laparoscopic Liver Resection for Liver Malignancies in Elderly Patients

PURPOSE

Laparoscopic liver resection is safe, feasible and associated with less blood loss, shorter hospital stays and fewer postoperative complications in the working age patients with malignant liver tumors. However, it is still unclear if the elderly patients with malignant liver tumors would also benefit from that approach as the younger patients. So, the aim of the study was to compare the clinical outcomes of laparoscopic versus open liver resection for malignant liver tumors in elderly patients.

MATERIALS AND METHODS

Between March 2009 and July 2016, all elderly patients (≥70 years old) who underwent laparoscopic (n = 40) and open (n = 202) liver resection for malignant liver tumors were included. A one to one propensity score matching analysis was performed, based on 6 covariates, to decrease the selection bias.

RESULTS

There was no significant difference between the laparoscopic and open liver resection groups regarding the patient characteristics and tumor features. The operative time was comparable between both groups (Laparoscopic group 259 min vs Open group 308 min, p = .86), while patients who underwent laparoscopic liver resection had lower intraoperative blood loss (30 ml vs 517 ml, p < .0001), shorter hospital stays (10 days vs 23 days, p < .0001), and less overall morbidity (15% vs 38%, p = .04). The one-, three-, and five-year survival for patients with hepatocellular carcinoma was comparable between both groups (Laparoscopic group 96%, 74%, 47%, vs Open group 94%, 71%, 48%, p = .82), whereas The one-, three-, and five-year recurrence-free survival for patients with hepatocellular carcinoma was significantly higher in the laparoscopic group (88%, 60%, 60% vs 54%, 25%, 19%, p = .019).

CONCLUSIONS

Laparoscopic approach for minor liver resection in elderly patients is safe and feasible with less blood loss, a shorter hospital stay, less postoperative complications and a better oncological outcome.

Coexistent End-stage Nonalcoholic Steatohepatitis and Colon Cancer: Should We Do Liver Transplantation?

BACKGROUND

Colon cancer accompanying decompensated liver cirrhosis is a rare clinical condition. Usually, treatment of colon cancer is prioritized, with cirrhosis dealt with later.

CASE REPORT

We present a case of end-stage liver disease due to nonalcoholic steatohepatitis evaluated for living donor liver transplant. During the pretransplant examination, an ascending colon cancer was detected. Liver function was too poor to perform colon resection first. Simultaneous living donor liver transplant and colonic resection were carried out. The patient developed left lung metastasis at 2 different times during the first postoperative year, and both of them were resected. The patient received the standard chemoradiotherapy. Now, the patient is alive at 42 months postprocedure and recurrence-free at 31 months postoperatively.

CONCLUSION

Simultaneous liver transplantation and colon resection are possible with acceptable long-term outcomes. Immunosuppressive therapy after transplantation increases the risk for cancer recurrence. So the patient should undergo close surveillance.

Evaluation of safety of concomitant splenectomy in living donor liver transplantation: a retrospective study

In Asian countries, concomitant splenectomy in living donor liver transplantation (LDLT) is indicated to modulate the portal vein pressure in the small-sized graft to protect against small for size syndrome. While concomitant splenectomy in deceased donor liver transplantation is almost contraindicated based on Western Reports of increased mortality and morbidity rate due to septic complications, there are few studies about that in LDLT. So, we retrospectively investigated the clinical outcome of adult LDLT at Kyoto University Hospital from July 2010 to July 2016. We divided the patients (n = 164) into those with concomitant splenectomy (n = 88) and those without (n = 76). The splenectomy group showed significantly increased operative time and intraoperative blood loss (P = 0.008, P = 0.0007, respectively), and significantly higher rate of postoperative splenic vein thrombosis and cytomegalovirus infection (P = 0.03, P = 0.016, respectively). However, there were no significant differences between the two groups regarding the incidence of postoperative hemorrhage (P = 0.06), post-transplant bacteremia (P = 0.38), infection-related mortality rates (P = 0.8), acute rejection (P = 0.87), and patient and graft survival (P = 0.66, P = 0.67 respectively); finally, model for end-stage liver disease score above 30 was an independent predictor for infection-related mortality post-transplant (HR = 5.99, 95% CI = 2.15-16.67, P = 0.001). In conclusion, concomitant splenectomy in LDLT can be safely performed when indicated.

Re-laparotomy after caesarean deliveries: risk factors and how to avoid?

The aim of this study was to explore the risk factors for and how to avoid re-laparotomy after caesarean delivery and to present the experience of a university tertiary care referral hospital. The study comprised of 2,000 caesarean deliveries, among which re-laparotomy was needed in 18 patients (0.9). The study found that 16 of the 18 cases that needed re-laparotomy had previous caesarean sections (CS) and 9/18 had placenta praevia. The main indication for the procedure was internal haemorrhage (haemoperitoneum) (12/18, 66.6%). Significant haemoperitoneum of > 2 litres was reported in six cases (33.3%). Maternal mortality occurred in 3/18 (16.6%) patients. The uterus was preserved in most patients (15 patients, 83.3%). A total of 12 patients needed re-suturing of the uterine incision; 10 patients had bilateral uterine artery ligation; and four patients had bilateral internal iliac artery ligation. Uterine compression B-Lynch suturing was needed in five patients with uterine atony. Six patients (33.3%) were admitted to the intensive care unit (ICU) and were discharged well. Re-laparotomy after caesarean delivery has many risk factors leading to postoperative haemorrhage. Early signs, such as tachycardia and hypotension must be closely monitored to allow early intervention and to avoid morbidity and mortality related to late re-laparotomy.

Matrix metalloproteinase-9 gene polymorphism in hepatocellular carcinoma patients with hepatitis B and C viruses

Hepatocellular carcinoma (HCC) is the fifth most common malignancy worldwide. In Egypt, the incidence of HCC has doubled over the last decade. Matrix metalloproteinase-9 (MMP-9) plays a key role in cancer invasion and metastasis by degrading the extracellular matrix and basement membrane barriers. A cytosine (C)/thymidine (T) single nucleotide polymorphism at position -1562 in the MMP-9 promoter is reported to influence the expression of the MMP-9 gene. The association between MMP-9 gene polymorphisms and HCC patients with hepatitis C and B viruses (HCV and HBV) was examined in 91 patients with HCC and viral hepatitis (55 HCV and 36 HBV). The results were compared with those of 42 HCC patients without viral hepatitis and 60 healthy individuals with no liver infection. Polymorphisms of the MMP-9 gene were investigated by polymerase chain reaction amplification followed by restriction fragment length polymorphism analysis. The serum MMP-9 level was quantitatively determined using a human MMP-9 enzyme-linked immunosorbent assay, which showed that homozygosity of the MMP-9 promoter (TT) was more frequent in patients with HCC and chronic HCV or HBV infection when compared with the control group (49.1, 52.8, and 35.7%, respectively). In addition, we observed significant elevation of serum MMP-9 levels in all HCC groups compared to controls. It was concluded that patients with the MMP-9 TT genotype are at risk of developing HCC and HBV or HCV. People with significantly elevated serum levels of MMP-9 are at risk of developing HCC.

The impact of wound age on the infection rate of simple lacerations repaired in the emergency department

BACKGROUND

The influence of wound age on the risk of infection in simple lacerations repaired in the emergency department (ED) has not been well studied. It has traditionally been taught that there is a "golden period" beyond which lacerations are at higher risk of infection and therefore should not be closed primarily. The proposed cutoff for this golden period has been highly variable (3-24h in surgical textbooks). Our objective is to answer the following research question: are wounds closed via primary repair after the golden period at increased risk for infection?

METHODS

We searched MEDLINE, EMBASE, and other databases as well as bibliographies of relevant articles. We included studies that enrolled ED patients with lacerations repaired by primary closure. Exclusion: (1) delayed primary repair or secondary closure, (2) wounds requiring intra-operative repair, skin graft, drains, or extensive debridement, and (3) grossly contaminated or infected at presentation. We compared the outcome of wound infection in two groups of early versus delayed presentations (based on the cut-offs selected by the original articles). We used "Grading of Recommendations Assessment, Development and Evaluation" (GRADE) criteria to assess the quality of the included trials.

RESULTS

418 studies were identified. Four trials enrolling 3724 patients in aggregate met our inclusion/exclusion criteria. The overall quality of evidence was low. The infection rate in the wounds that presented with delay ranged from 1.4% to 32%. One study with the smallest sample size (only 19 delayed wounds), which only enrolled lacerations to hand and forearm, showed higher rate of infection in patients with delayed (older than 12h) wounds (relative risk of infection: 4.8, 95% confidence interval, 1.9-12.0). The infection rate in delayed wound groups in the remaining three studies was not significantly different.

CONCLUSION

The existing evidence does not support the existence of a golden period nor does it support the role of wound age on infection rate in simple lacerations.

Subfertility treatment in women with systemic lupus erythematosus

This study comprised of 65 infertile patients with systemic lupus erythematosus (SLE). The aim was to study causes and different modalities used for the management of subfertile patients with SLE. All patients were diagnosed to have SLE according to the standard criteria of diagnosis. All patients were scheduled to expectant treatment, ovulation induction and timed intercourse, intrauterine insemination (IUI), intracytoplasmic sperm injection (ICSI). Anovulation was in 20 patients (20%), due to PCOS in 10 cases and due to other causes in three patients. A total of 28 patients (43.1%) needed laparoscopy for their work-up of infertility. Male factor for infertility was present in nine couples (16.7%). Ovulation induction and timed intercourse was adopted for a maximum 6 cycles and IUI for 3 cycles. In vitro fertilisation (IVF)/ICSI was needed in five cases using standard long agonist protocol. Four cases were complicated by significant ovarian hyperstimulation syndrome after conventional ovarian stimulation and cycles were cancelled. Pregnancy occurred in 20 women. Ovarian stimulation for ovulation induction and IVF seems to be safe and successful in well selected women with non-complicated SLE.

Clomiphene citrate or aromatase inhibitors combined with gonadotropins for superovulation in women undergoing intrauterine insemination: a prospective randomised trial

The objective of this study was to test the use of letrozole in combination with follicle-stimulating hormone (FSH) vs clomiphene citrate (CC) with FSH for ovarian hyperstimulation prior to intrauterine insemination (IUI). A prospective randomised trial in which 280 women with unexplained infertility were randomised to 100 mg of CC (141 patients, 219 cycles) or 5 mg of letrozole daily (139 patients, 215 cycles) for 5 days starting on day 3 of menses both combined with gonadotropins for ovarian stimulation prior to IUI. The primary outcome measures were the number of growing and mature follicles, the concentrations of serum E2 (pg/ml) and progesterone (ng/ml), and the endometrial thickness (mm). The secondary outcome measure was the occurrence of pregnancy and miscarriage. The total number of follicles was significantly greater in the CC group (4.1 +/- 0.46 vs 2.6 +/- 0.43). There was no significant difference in endometrial thickness between the two groups. Pregnancy occurred in 33 out of 139 patients (215 cycles) in the letrozole group (23.7% and 15.3%, respectively) and 37 out of 141 patients (219 cycles) (26.2% and 16.8%, respectively) in the CC group; the differences were not statistically significant. The allied use of either CC or letrozole, during ovarian stimulation to reduce the dose of gonadotropins prior to IUI is justified. This approach will reduce the cost of stimulation protocols without effect on the treatment outcome and letrozole has no advantage over CC in this respect.

Can thyroid dysfunction explicate severe menopausal symptoms?

Many of the menopausal manifestations look like those accredited to thyroid hyperfunction or hypofunction. Can thyroid dysfunction explicate severe menopausal symptoms? The study comprised 350 women with different menopausal symptoms. All women had serum TSH, T3 and free T4 estimated. Women with thyroid dysfunction were appropriately treated and other women were treated with ERT. The study showed that 21 women (6%) had hypothyroidism and 18 (5.1%) had hyperthyroidism. Marked improvement in the menopausal-like symptoms occurred after treatment of the thyroid dysfunction. Elderly women with severe or resistant menopausal symptoms can be offered TSH, T3 and T4 assays to rule out the thyroid disturbances before attempting hormone replacement therapy.

Induction of ovulation in idiopathic premature ovarian failure: a randomized double-blind trial

In this prospective randomized study, women with idiopathic karyotypically normal premature ovarian failure (POF) were treated with gonadotrophin-releasing hormone (GnRH) agonist and gonadotrophins with and without the addition of corticosteroids in an attempt to restore ovarian function. The study comprised 58 women with idiopathic POF randomly allocated to either GnRH agonists (GnRHa) plus gonadotrophin therapy with the addition of corticosteroids (29 patients) or GnRHa plus gonadotrophin therapy with placebo (29 patients). Ovulation occurred in six cases (20.7%) in the dexamethasone group versus three cases (10.3%) in the placebo group. There were two singleton pregnancies in the dexamethasone group. There were no reported complications from the use of dexamethasone apart from a sense of sleepiness and fatigue. The combination of corticosteroids with pituitary suppression followed by ovarian stimulation with gonadotrophin appeared to be beneficial in restoring ovarian function in patients with idiopathic POF and normal karyotype.

Randomized controlled trial of three doses of letrozole for ovulation induction in patients with unexplained infertility

The aromatase inhibitor letrozole is a novel agent that can be used as an alternative to clomiphene citrate for ovulation induction in patients with unexplained infertility. The dose of letrozole used has varied between studies, and this study aimed to compare the three most commonly used doses: 2.5, 5 and 7.5 mg. A total of 179 patients were randomly recruited in this prospective study with 58, 61 and 60 patients in each dosage group respectively. This study reports a significantly higher (P < 0.05) number of follicles (total, > 14 mm and > or = 18 mm) on the day of administration of human chorionic gonadotrophin in the 7.5 mg group, associated with significantly fewer (P < 0.05) days of stimulation. However the pregnancy and miscarriage rates were similar in the three groups. In conclusion, it seems that the use of higher doses of letrozole offers no advantage in terms of pregnancy rates over the lower (2.5 mg) dose.

The effect of smoking on brainstem auditory evoked potentials in positive- and negative-symptom schizophrenia

Studying brainstem auditory evoked potentials (BAEPs) and comparing the specific waves in smokers vs nonsmokers in both positive- and negative-symptom schizophrenia may elucidate the role of smoking in information processing. BAEPs were recorded in 40 patients with schizophrenia; 20 had predominantly positive symptoms (10 smokers and 10 nonsmokers) and 20 had predominantly negative symptoms (10 smokers and 10 nonsmokers). The severity of positive and negative symptoms was assessed by scale of assessment of positive symptoms and scale of assessment of negative symptoms (SANS). The BAEP results were compared with 15 healthy control individuals matched with the patients by age, sex, and cultural background. The smokers with negative symptoms showed a significant increase in the alogia, summary, and composite scores of SANS as compared to the nonsmokers. Although, most of the BAEP abnormalities were among patients with positive symptoms. The effect of smoking on the BAEPs was only in patients with negative symptoms. We also studied the interaction between smoking factor (smokers vs nonsmokers) and group type (group with mostly positive symptoms vs group with mostly negative symptoms) on the BAEPs and found a significant difference only for the first-wave latency mainly on the right side (P=0.012). The absence of a significant effect of smoking on most of the parameters of the BAEPs on interaction with the group factor suggests that the effect of smoking on the BAEPs is more apparent when negative symptoms prevail. However, studies are warranted to substantiate this finding.