Examining Results of Post-Thelarche Screening Pelvic Ultrasound in Females with Anorectal Malformations

STUDY OBJECTIVE

Mullerian duct anomalies are common in females with anorectal malformations (ARM), though there are no universally recommended screening protocols for identification. Historically, at our institution, we have recommended a screening pelvic ultrasound six months after thelarche and menarche. We aimed to evaluate outcomes associated with our post-thelarche screening pelvic ultrasounds (PUS) in females with ARM.

METHODS

An IRB-approved retrospective chart review was performed of all female patients ≥ 8 years old with ARM and documented thelarche. Data was collected on demographics and clinical course. Primary outcome was adherence to recommended PUS. Secondary outcomes included imaging correlation with suspected Mullerian anatomy and need for intervention based on imaging findings.

RESULTS

A total of 112 patients met inclusion criteria. Of these, 87 (77.7%) completed a recommended post-thelarche screening PUS. There were no differences in completion based on age, race, establishment with a primary care provider, insurance status, or type of ARM. Nine patients (10.3%) had findings on their PUS that did not correlate with their suspected Mullerian anatomy; five (5.7%) required intervention with two requiring menstrual suppression, two requiring surgical intervention, and one requiring further imaging.

CONCLUSION

Most patients completed the recommended post-thelarche screening PUS. In a small subset of patients, PUS did not correlate with suspected Mullerian anatomy and generated a need for intervention. Post-thelarche PUS can be a useful adjunct in patients with ARM to identify gynecologic abnormalities.

Reducing Unnecessary Oophorectomies for Benign Ovarian Neoplasms in Pediatric Patients

Importance

Although most ovarian masses in children and adolescents are benign, many are managed with oophorectomy, which may be unnecessary and can have lifelong negative effects on health.

Objective

To evaluate the ability of a consensus-based preoperative risk stratification algorithm to discriminate between benign and malignant ovarian pathology and decrease unnecessary oophorectomies.

Design, Setting, and Participants

Pre/post interventional study of a risk stratification algorithm in patients aged 6 to 21 years undergoing surgery for an ovarian mass in an inpatient setting in 11 children's hospitals in the United States between August 2018 and January 2021, with 1-year follow-up.

Intervention

Implementation of a consensus-based, preoperative risk stratification algorithm with 6 months of preintervention assessment, 6 months of intervention adoption, and 18 months of intervention. The intervention adoption cohort was excluded from statistical comparisons.

Main Outcomes and Measures

Unnecessary oophorectomies, defined as oophorectomy for a benign ovarian neoplasm based on final pathology or mass resolution.

Results

A total of 519 patients with a median age of 15.1 (IQR, 13.0-16.8) years were included in 3 phases: 96 in the preintervention phase (median age, 15.4 [IQR, 13.4-17.2] years; 11.5% non-Hispanic Black; 68.8% non-Hispanic White); 105 in the adoption phase; and 318 in the intervention phase (median age, 15.0 [IQR, 12.9-16.6)] years; 13.8% non-Hispanic Black; 53.5% non-Hispanic White). Benign disease was present in 93 (96.9%) in the preintervention cohort and 298 (93.7%) in the intervention cohort. The percentage of unnecessary oophorectomies decreased from 16.1% (15/93) preintervention to 8.4% (25/298) during the intervention (absolute reduction, 7.7% [95% CI, 0.4%-15.9%]; P = .03). Algorithm test performance for identifying benign lesions in the intervention cohort resulted in a sensitivity of 91.6% (95% CI, 88.5%-94.8%), a specificity of 90.0% (95% CI, 76.9%-100%), a positive predictive value of 99.3% (95% CI, 98.3%-100%), and a negative predictive value of 41.9% (95% CI, 27.1%-56.6%). The proportion of misclassification in the intervention phase (malignant disease treated with ovary-sparing surgery) was 0.7%. Algorithm adherence during the intervention phase was 95.0%, with fidelity of 81.8%.

Conclusions and Relevance

Unnecessary oophorectomies decreased with use of a preoperative risk stratification algorithm to identify lesions with a high likelihood of benign pathology that are appropriate for ovary-sparing surgery. Adoption of this algorithm might prevent unnecessary oophorectomy during adolescence and its lifelong consequences. Further studies are needed to determine barriers to algorithm adherence.

Impact of Pelvic Floor Physical Therapy on Function in Adolescents and Young Adults with Biopsy-Confirmed Endometriosis at a Tertiary Children's Hospital: A Case Series

STUDY OBJECTIVE

The purpose of this case series is to describe the change in capability to perform self-selected activities in adolescent and young adult patients with chronic pelvic pain and surgically proven endometriosis following pelvic floor physical therapy as part of multidisciplinary treatment.

DESIGN

Retrospective case series SETTING: Tertiary care pediatric hospital PARTICIPANTS: Twenty patients with ages ranging from 14 to 22 years and a median age of 16.5 years with biopsy-confirmed endometriosis INTERVENTION: Pelvic floor physical therapy MAIN OUTCOME MEASURE(S): Patient-Specific Functional Scale (PSFS) outcome measure RESULTS: Patients had a clinically significant functional improvement (median score of 6.0 points on the PSFS outcome measure; interquartile range, 3.8-13.5) over the course of care (median number of 12 visits; range 4-48 visits) (P < .001).

CONCLUSIONS

Patients with chronic pelvic pain and surgically proven endometriosis experienced significant functional improvement after physical therapy treatment. The results of this case series suggest that physical therapy is a viable additional intervention for adolescents and young adults with chronic pelvic pain and endometriosis and warrants further research.

Comparing the Evaluation of Abdominal Pain in Adolescent Females at a Pediatric vs General Emergency Department

BACKGROUND

The objective of this study was to determine the rates at which gynecologic history and related exams are performed among adolescent females presenting with abdominal pain and whether the rates differ between patients seeking care at a pediatric compared with a general emergency department (ED).

METHODS

We conducted a retrospective cohort study of female patients aged 12-21 years who presented to the ED for a chief complaint of abdominal pain at either a single academic children's ED or a single general academic ED during 2016. We examined differences in the rates of gynecologic history and related exams between institutions, before and after adjustment with inverse probability weights.

RESULTS

A total of 837 females met the inclusion criteria for this study, and 627 patients were included in the adjusted analyses. Outcomes more commonly performed at the pediatric institution included documentation of contraception (28% at the general ED vs 43% at the pediatric ED, P < .001), sexually transmitted infection testing (32% at the general ED vs 42% at the pediatric ED, P = .04), and radiologic imaging (46% at the general ED vs 70% at the pediatric ED, P < .001). Outcomes that were more commonly performed at the general ED were pelvic exam (26% at the general ED vs 10% at the pediatric ED, P < .001) and complete blood count draw (67% at the general ED vs 39% at the pediatric ED, P < .001). No differences were observed between institutions in the documentation of menarche or sexual activity, the performance of a pregnancy test or CT scan, or the rate of subsequent ED/urgent care visits in the following year.

CONCLUSION

The rates at which gynecologic history and pelvic examination were performed in adolescent females presenting for abdominal pain at both a general ED and a pediatric ED were low and inconsistent. Providers should have a low threshold for testing for sexually transmitted infections and pregnancy. Pelvic examination and diagnostic lab testing should be performed when indicated in the setting of a clinically appropriate history. These efforts would ensure adequate evaluation of adolescent women and reduce unnecessary health resource utilization.

Fetus-in-Fetu: A Case of Ovarian Involvement and Residual Regrowth in a Teenager

BACKGROUND

Fetus-in-fetu (FIF) is a rare, congenital soft tissue mass typically occurring retroperitoneally in neonates younger than 18 months. We present a 13-year-old girl with an ovarian FIF occurrence and subsequent residual regrowth after resection.

CASE

A 13-year-old girl presented with abdominal pain and was found to have a 19-cm, complex, right adnexal mass. Preoperative tumor markers were normal and risk assessment favored a benign process. She underwent open ovarian cystectomy with pathology showing FIF. Nine months later, she had a recurrence of her ovarian mass and underwent right oophorectomy, with FIF on pathology.

SUMMARY AND CONCLUSION

In patients in whom FIF is discovered within the ovary, consider postoperative surveillance, because of the risk of recurrence or residual disease.

Reconsidering Diagnosis, Treatment, and Postoperative Care in Children with Cloacal Malformations

Cloacal malformations are among the most complex types of anorectal malformation and are characterized by the urological, genital, and intestinal tracts opening through a single common channel in the perineum. Long-term outcome is affected by multiple factors, which include anatomical variants of the malformation itself, associated anomalies, and the surgical approach. Reconsidering these variables and their influence on "patient important" function might lead to strategies that are more outcome-driven than focused on the creation of normal anatomy. Key outcomes reflect function in each of the involved tracts and the follow-up needed should therefore not only include the classical fields of colorectal surgery and urology but also focus on items such as gynecology, sexuality, family-building, and quality of life as well as other psychological aspects. Involving patients and families in determining optimal treatment strategies and outcome measures could lead to improved outcomes for the individual patient. A strategy to support delivery of personalized care for patients with cloacal malformations by aiming to define the best functional outcomes achievable for any individual, then select the treatment pathway most likely deliver that, with the minimum morbidity and cost, would be attractive. Combining the current therapies with ongoing technological advances such as tissue expansion might be a way to achieve this.

Emergency Department Evaluation of Abdominal Pain in Female Adolescents

STUDY OBJECTIVE

Evaluation of acute abdominal pain in an adolescent female patient should include consideration of all potential sources of pain, including gynecologic etiologies. The goal of our study was to determine the frequency of evaluation of gynecologic causes of abdominal pain in adolescent girls seen in a pediatric emergency department.

STUDY DESIGN

A retrospective review was performed of girls between 12 and 21 years of age presenting to the emergency department or urgent care centers at a single pediatric institution with the chief complaint of abdominal pain during 2016. Frequency analyses of demographic and clinical characteristics are presented.

RESULTS

A total of 1082 girls presented with a chief complaint of abdominal pain. Menarche was documented in 85% of patients, sexual history in 52% of patients, and assessment of contraception use in 28%. Pregnancy testing was performed in 77%. Sexually transmitted infection (STI) testing was performed in 31%, and in only 73% of patients who reported being sexually active. Imaging was performed in 52%. In the subgroup of patients who reported being sexually active and presented with abdominal pain and vaginal discharge, only 37% had a pelvic examination performed. In multivariable modeling, Black patients were significantly more likely than White patients to have STI testing performed (adjusted risk ratio [aRR] = 1.39; confidence interval [CI] = 1.13-1.70) and to undergo a pelvic examination (aRR = 2.45; CI = 1.34-4.50), and less likely to undergo imaging (aRR = 0.69; CI = 0.59-0.81).

CONCLUSION

The assessment of abdominal pain in adolescent girls should include gynecologic etiologies. Our results raise concerns that there are deficiencies in the evaluation of gynecologic sources of abdominal pain in girls treated at pediatric facilities, and evidence of potential racial disparities.

Experiences and attitudes of young adults with congenital bowel and bladder conditions

INTRODUCTION

Young adults with complex congenital bowel and bladder anomalies are a vulnerable population at risk for poor health outcomes. Their experiences with the healthcare system and attitudes towards their health are understudied.

OBJECTIVE

Our objective was to describe how young adults with congenital bladder and bowel conditions perceive their current healthcare in the domains of bladder and bowel management, reproductive health, and transition from pediatric to adult care.

STUDY DESIGN

At a camp for children with chronic bowel and bladder conditions, we offered a 50-question survey to the 62 adult chaperones who themselves had chronic bowel and bladder conditions. Of the 51 chaperones who completed the survey (a response rate of 82%), 30 reported a congenital condition and were included.

RESULTS

The cohort of 30 respondents had a median age of 23 years and almost half of the subjects (46%) reported not having transitioned into adult care. Most reported bowel (81%) and bladder (73%) management satisfaction despite high rates of stool accidents (85%), urinary accidents (46%), and recurrent urinary tract infections (70%). The majority of respondents (90%) expressed interest in having a reproductive health provider as part of their healthcare team. The median ages of the first conversation regarding transition to adult care and feeling confident in managing self-healthcare were 18 and 14 years, respectively. Most (85%) reported feeling confident in navigating the medical system.

DISCUSSION

In this cohort of young adults who reported confidence with self-care and navigating the medical system, the proportion who had successfully transitioned into to adult care was low. These data highlight the need for improved transitional care and the importance of patient-provider and provider-provider communication throughout the transition process.

CONCLUSION

These data highlight the need to understand the experience of each individual patient in order to provide care that aligns with their goals.

Factors Associated with Torsion in Pediatric Patients with Ovarian Masses

BACKGROUND

Management of ovarian torsion has evolved toward ovarian preservation regardless of ovarian appearance during surgery. However, patients with torsion and an ovarian neoplasm undergo a disproportionately high rate of oophorectomy. Our objectives were to identify factors associated with ovarian torsion among females with an ovarian mass and to determine if torsion is associated with malignancy.

METHODS

A retrospective review of females aged 2-21 y who underwent an operation for an ovarian cyst or neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariate logistic regression was used to assess factors associated with torsion. Imaging data were assessed for sensitivity, specificity, and predictive value in identifying ovarian torsion.

RESULTS

Of 814 girls with an ovarian neoplasm, 180 (22%) had torsion. In risk-adjusted analyses, patients with a younger age, mass size >5 cm, abdominal pain, and vomiting had an increased likelihood of torsion (P < 0.01 for all). Patients with a mass >5 cm had two times the odds of torsion (odds ratio: 2.1; confidence interval: 1.2, 3.6). Imaging was not reliable at identifying torsion (sensitivity 34%, positive predictive value 49%) or excluding torsion (specificity 72%, negative predictive value 87%). The rates of malignancy were lower in those with an ovarian mass and torsion than those without torsion (10% versus 17%, P = 0.01). Among the 180 girls with torsion and a mass, 48% underwent oophorectomy of which 14% (n = 12) had a malignancy.

CONCLUSIONS

In females with an ovarian neoplasm, torsion is not associated with an increased risk of malignancy and ovarian preservation should be considered.

Change over time in adolescent smoking, cannabis use and their association: findings from the School Health Research Network in Wales

Background

While tobacco smoking has declined among UK youth in recent decades, cannabis use has begun to show some growth. Given their interrelationship, growth in cannabis use may act as a barrier to continued reduction in youth smoking. This paper assesses recent tobacco and cannabis use trends in Wales, and their association, to explore whether change in cannabis use might have impacted youth tobacco smoking prevalence.

Methods

Repeat cross-sectional data on tobacco and cannabis use were obtained from biennial Welsh Student Health and Wellbeing surveys between 2013 and 2019. Data were pooled and analysed using logistic regression with adjustment for school-level clustering.

Results

No change in regular youth tobacco smoking was observed between 2013 and 2019. In contrast, current cannabis use increased during this time, and cannabis users had significantly greater odds of regular tobacco smoking. After adjusting for change in cannabis use, a significant decline in youth tobacco smoking was observed (OR 0.95; 95% confidence intervals: 0.92, 0.97).

Conclusion

Recent growth in cannabis use among young people in Wales may have offset prospective declines in regular tobacco smoking. Further reductions in youth smoking may require more integrated policy approaches to address the co-use of tobacco and cannabis among adolescents.

Understanding the Value of Tumor Markers in Pediatric Ovarian Neoplasms

PURPOSE

The purpose of this study was to determine the diagnostic accuracy of tumor markers for malignancy in girls with ovarian neoplasms.

METHODS

A retrospective review of girls 2-21 years who presented for surgical management of an ovarian neoplasm across 10 children's hospitals between 2010 and 2016 was performed. Patients who had at least one concerning feature on imaging and had tumor marker testing were included in the study. Sensitivity, specificity, and negative and positive predictive values (PPV) of tumor markers were calculated.

RESULTS

Our cohort included 401 patients; 22.4% had a malignancy. Testing for tumor markers was inconsistent. AFP had high specificity (98%) and low sensitivity (42%) with a PPV of 86%. The sensitivity, specificity, and PPV of beta-hCG was 44%, 76%, and 32%, respectively. LDH had high sensitivity (95%) and Inhibin A and Inhibin B had high specificity (97% and 92%, respectively).

CONCLUSIONS

Tumor marker testing is helpful in preoperative risk stratification of ovarian neoplasms for malignancy. Given the variety of potential tumor types, no single marker provides enough reliability, and therefore a panel of tumor marker testing is recommended if there is concern for malignancy. Prospective studies may help further elucidate the predictive value of tumor markers in a pediatric ovarian neoplasm population.

TYPE OF STUDY

Retrospective Cohort Review.

LEVEL OF EVIDENCE

Level III.

Obstetrical Outcomes in Adult Patients Born with Complex Anorectal Malformations and Cloacal Anomalies: A Literature Review

Patients born with complex anorectal malformations often have associated Müllerian anomalies, which might affect fertility and obstetrical outcomes. Other vertebral-anorectal-tracheoesophageal-renal-limb associations, such as renal or cardiac anomalies, could also affect pregnancy intention, fertility rates, and recommendations about mode of delivery or obstetrical outcomes. Associated conditions present at birth, like hydrocolpos, could also potentially affect fertility. Depending on the complexity of the anomaly, primary reconstruction might include vaginoplasty, vaginal interposition, perineal body reconstruction, and extensive pelvic dissection. After the initial reconstruction, patients might have multiple additional surgeries for stoma reversal, bladder augmentation, and creation of conduits, all with potential for pelvic adhesions. Pregnancy intention, fertility rates, mode of delivery, and obstetrical outcomes data are limited in this patient population, making it challenging to counsel patients and their families. We sought to evaluate all available literature in an attempt to better counsel families. A PubMed literature search was undertaken to review this topic. Search terms of "cloaca," "anorectal malformation," "pregnancy," "cloacal exstrophy," "vaginal delivery," and "cesarean section" were used and citation lists from all identified articles were checked to ensure that all possible articles were included in the review. We also outline comorbidities from the fetal period to adulthood that might affect reproductive health. Of the articles on anorectal and cloacal anomalies, 13 reports were identified that covered obstetrical outcomes. They were in patients with previous anorectal malformation, cloaca, and cloacal exstrophy repair. Twenty-four pregnancies were reported in 16 patients. Two ectopic pregnancies, 5 spontaneous miscarriages, 1 triplet pregnancy, and 16 singleton pregnancies were reported with a total of 19 live births. Regarding the method of conception, 15/18 pregnancies occurred spontaneously and 3/18 were via assisted reproductive technology with in vitro fertilization. There were 19 live births, of which at least 8 were preterm. Müllerian anatomy was reported in 8 of 13 articles. Only 2 patients underwent vaginal delivery (1 patient with repaired cloaca malformation had an operative vaginal delivery and 1 patient with repaired imperforate anus with rectovaginal fistula had a normal spontaneous vaginal delivery). The remaining patients all underwent a cesarean section. There were no reported cases of maternal mortality, and maternal morbidity was limited to recurrent urinary tract infections and worsening chronic kidney disease. There is a paucity of information regarding obstetrical outcomes in adult anorectal and cloaca patients. However, patients with previous cloacal repairs have achieved pregnancy spontaneously, as well as with in vitro fertilization. Patients with repaired cloacal malformations are at increased risk of preterm birth and cesarean delivery. Most patients with cloacal anomalies have an associated Müllerian anomaly and therefore have an increased risk of preterm labor. From our review we conclude that contraception should be offered to patients not desiring pregnancy, and cesarean section is likely the preferred mode of delivery. On the basis of this review, we recommend proactive data collection of all such patients to document outcomes and collaboration among providers and between centers devoted to this complex patient population.

Prolonged Vaginal Bleeding in an Adolescent Secondary to a Foreign Body: Need for a Comprehensive Assessment and Complex Surgery

BACKGROUND

Heavy, prolonged menstrual bleeding is common in adolescents and results from a variety of etiologies.

CASE

A 13-year-old, virginal girl was referred for prolonged, heavy vaginal bleeding despite combined oral contraceptive use and elected management with a levonorgestrel intrauterine device. A preprocedure exam revealed a plastic foreign body embedded in the posterior vaginal fornix, however, attempted removal in the office was unsuccessful. Subsequent computed tomography imaging of the pelvis revealed a vaginal foreign body, complex adnexal mass, and hydroureter. The patient underwent exam under anesthesia and diagnostic laparoscopy, but required conversion to exploratory laparotomy for removal of a foreign body because of vaginal perforation abutting the rectum.

SUMMARY AND CONCLUSION

Foreign bodies not easily removed in the outpatient setting should be considered for surgical removal with consideration of preoperative multidisciplinary coordination when imaging reveals intra-abdominal pathology, such as tubo-ovarian abscess and hydroureter.

Cloaca reconstruction: a new algorithm which considers the role of urethral length in determining surgical planning

BACKGROUND

Cloacal malformations represent a uniquely complex challenge for surgeons. The surgical approach to date has been based on the common channel (CC) length with two patient groups considered: less than or greater than 3cm, which we believe is an oversimplification. We reviewed 19 patients, referred after surgery done elsewhere. Eight had postoperative urinary complications, 3 had constant urinary leakage and had been left after surgery with a urethra <1cm, .5 with an original 3 to 5cm common channel, who had undergone total urogenital mobilization (TUM), experienced peri-operative urethral loss needing a vesicostomy, and later, a Mitrofanoff. These patients together with a review of the cloacal and urological literature led us to design a new algorithm where urethral length is a key determinant for care.

METHODS

We prospectively collected data on 31 consecutive cloaca patients referred to our team (2014 to 2016) and managed according to this new protocol. The CC length, urethral length, surgical technique employed, and initial outcomes were recorded.

RESULTS

Of 31 primary cases, CC length was 1 to 3cm in 20, 3 to 5cm in 9, and greater than 5cm in 2. In the 1 to 3cm and the 3 to 5cm groups, a urethra less than 1.5cm led us to perform an urogenital separation. We only performed a TUM if the urethra was greater than 1.5cm. Using this protocol, we performed a urogenital separation in 1 of 20 in the 1 to 3cm CC group, 6 of 9 in the 3 to 5cm CC group, and 2 of 2 in the greater than 5cm CC group. Seven patients underwent separation, who with the previous approach, would have had a TUM. Thus far, no urinary leakage or urethral loss has occurred in any patient, but follow-up is less than 3years.

CONCLUSION

Urethral length appears to be a vitally important component in cloacal reconstruction. A short urethra left after repair can lead to urinary leakage. A TUM done under the wrong circumstances can lead to urethral loss. We describe a new technical approach to cloacal repair which considers urethral length but recognize that long term urological outcomes will need to be carefully documented.

TYPE OF STUDY

Clinical cohort study with no comparative group.

LEVEL OF EVIDENCE

Level 4.

Development and testing of a questionnaire to measure patient satisfaction with intermediate care

BACKGROUND

Individual trials have suggested high levels of general patient satisfaction with intermediate care, but this topic has not been examined in detail.

AIMS

To identify the key elements of patient satisfaction with intermediate care, and to see whether these can be validly measured using a questionnaire.

METHOD

A questionnaire was developed on the basis of a literature review and piloting with patients and staff on participating schemes (phase I). In phase II, the questionnaire was tested for validity and reliability in a group of patients recently discharged from two "hospital-at-home" intermediate-care schemes. In phase III, a shortened version of the questionnaire was psychometrically tested in five sites taking part in a national evaluation of intermediate care.

RESULTS

96 patients with an average age of 76.5 years took part in phase II. Test-retest reliability was evaluated by repeating the questionnaire 2 weeks later in a subsample of 42 patients. This was "moderate" (kappa 0.4-0.6) for 12 questions, "fair" (kappa 0.2-0.4) for 6 questions and "poor" (kappa 0.1-0.2) for 5 questions. Scores correlated well with the Client Satisfaction Questionnaire (Spearman's r = 0.75, p<0.001). 843 patients (57% of those eligible) from five intermediate-care schemes took part in phase III. Principal components analysis suggested six factors or subscales: general satisfaction, affective response, cognitive response, timing of discharge, coordination after discharge, and access to pain relief, although the last three factors comprised only one question each. The intraclass correlation coefficients in the first three subscales varied from 0.82 to 0.89. Scores for all subscales differed by scheme, suggesting construct validity. Only one question (on general satisfaction) was found to be redundant.

CONCLUSION

The questionnaire, with some minor amendments to improve performance, could be used as a validated tool for audit and research in intermediate care. An amended version and scoring programme is available from us on request.

Genetic diversity and subdivision of 57 European and Middle-Eastern sheep breeds

The population structure and genetic diversity of 57 European and Middle Eastern marginal and cosmopolitan sheep breeds from 15 countries were analysed by typing 31 microsatellite markers. Mean unbiased expected heterozygosities ranged from 0.63 in British Exmoor Horn to 0.77 in Albanian Ruda. South-eastern European and Middle-Eastern sheep breeds were significantly more variable than northwestern and western European breeds. An overall heterozygote deficiency (f) across all loci was observed (P < 0.001), while genetic differentiation (theta) was 5.7%. Principal component analysis and Bayesian model-based clustering indicate a south-east to north-west cline, but also revealed distinct groups of Middle-Eastern fat-tailed sheep, south-eastern European sheep and north-western/western European sheep. Within the last group, two less-distinct clusters comprised the Merino-type and Alpine breeds respectively. The incomplete demarcations of most clusters probably reflects cross-breeding and/or upgrading.

The nutritional vulnerability of older Guyanese in residential homes

OBJECTIVE

To assess the nutritional status, functional ability and food intake of older Guyanese in residential care.

METHODS

Eighty-four residents of one public and two private homes underwent an anthropometric and functional ability assessment including height, weight, armspan, arm and calf circumferences and handgrip strength. Food intake in two private homes was measured over seven days by direct weighing and the use of consumption units.

RESULTS

The overall prevalence of underweight was 26.2% and of overweight was 17.8% but the prevalence of underweight was higher in the public home (29.3% underweight and 17.2% overweight in the public home, and 19.2% underweight and 19.2% overweight in the private home). Mean handgrip strength was 26 kg in males and 17.7 kg in females. The nutritional adequacy of the diet provided by one of the homes was poor with the food providing less than 50% of the required amount of zinc and vitamins A, D and C. Neither home met the requirement for energy.

CONCLUSION

A high prevalence of malnutrition exists in a public home for the elderly and, to a lesser degree, in two private homes. In the context of a rapidly ageing population and tight financial constraints, the challenge of providing an adequate diet must be given priority.

Dietary advice for reducing cardiovascular risk

BACKGROUND

Changes in population diet are likely to reduce cardiovascular disease and cancer, but the effect of dietary advice is uncertain.

OBJECTIVES

To assess the effects of providing dietary advice to achieve sustained dietary changes or improved cardiovascular risk profile among healthy adults.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register on The Cochrane Library (Issue 2 2000), MEDLINE (January 1966 to December 2000), EMBASE (January 1985 to December 2000), DARE (December 2000), CAB Health (December 1999), dissertation abstracts, and reference lists of articles. We contacted researchers in the field.

SELECTION CRITERIA

Randomised studies with no more than 20% loss to follow-up, lasting at least three months involving healthy adults comparing dietary advice with no advice or less intensive advice. Trials involving children, trials to reduce weight or those involving supplementation were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Twenty-three trials with 29 intervention arms (comparisons) comparing dietary advice with no advice were included in the review. Dietary advice reduced total serum cholesterol by 0.13 mmol/l (95% CI 0.03 to 0.23) and LDL cholesterol by 0.13 mmol/l (95% CI 0.01 to 0.25) after 3-12 months. Mean HDL cholesterol levels were unchanged. Dietary advice reduced blood pressure by 2.10 mmHg systolic (95% CI 1.37 to 2.83) and 1.63 mmHg diastolic (95% CI 0.56 to 2.71) and 24-hour urinary sodium excretion by 44.2 mmol (95% CI 33.6 to 54.7) after 3-36 months. Plasma triglycerides, ss-carotene and red cell folate were each measured in one small study which suggested no significant effect. Self-reported dietary intake may be subject to reporting bias, and there was significant heterogeneity in all the following analyses. Compared to no advice, dietary advice increased fruit and vegetable intake by 1.24 servings/day (95% CI 0.43 to 2.05). Dietary fibre intake increased with advice by 7.22 g/day (95% CI 2.84 to 11.60), while total dietary fat as a percentage of total energy intake fell by 6.18 % (95% CI 4.00 to 8.36) with dietary advice and saturated fat intake fell by 3.28 % (95% CI 1.92 to 4.64).

AUTHORS' CONCLUSIONS

Dietary advice appears to be effective in bringing about modest beneficial changes in diet and cardiovascular risk factors over approximately 9 months but longer term effects are not known.

Warning devices for prevention of dental injury during laryngoscopy. Preliminary report

The prototypes of two novel warning devices for protection against dental trauma during direct laryngoscopy are described. Either can be attached to a standard laryngoscope blade (e.g., Macintosh). The basic design is that of a switch that is closed by pressure on the maxillary incisors by the laryngoscope blade.

Opportunistic screening for genital chlamydial infection. I: acceptability of urine testing in primary and secondary healthcare settings

OBJECTIVES

To determine the acceptability of opportunistic screening for Chlamydia trachomatis in young people in a range of healthcare settings.

DESIGN

An opportunistic screening programme (1 September 1999 to 31 August 2000) using urine samples tested by ligase chain reaction (LCR). Data on uptake and testing were collected and in-depth interviews were used for programme evaluation.

SETTING

General practice, family planning, genitourinary medicine clinics, adolescent sexual health clinics, termination of pregnancy clinics, and women's services in hospitals (antenatal, colposcopy, gynaecology and infertility clinics) in two health authorities (Wirral and Portsmouth and South East Hampshire). Main participants: Sexually active women aged between 16 and 24 years attending healthcare settings for any reason.

MAIN OUTCOME MEASURES

Uptake data: proportion of women accepting a test by area, healthcare setting, and age; overall population coverage achieved in 1 year. Evaluation data: participants' attitudes and views towards opportunistic screening and urine testing.

RESULTS

Acceptance of testing by women (16-24 years) was 76% in Portsmouth and 84% in Wirral. Acceptance was lower in younger women (Portsmouth only) and varied by healthcare setting within each site. 50% of the target female population were screened in Portsmouth and 39% in Wirral. Both the opportunistic offer of screening and the method of screening were universally acceptable. Major factors influencing a decision to accept screening were the non-invasive nature of testing and treatment, desire to protect future fertility, and the experimental nature of the screening programme.

CONCLUSIONS

An opportunistic model of urine screening for chlamydial infection is a practical, universally acceptable method of screening.

Opportunistic screening for genital chlamydial infection. II: prevalence among healthcare attenders, outcome, and evaluation of positive cases

OBJECTIVES

To determine the prevalence and treatment outcomes among young women screened opportunistically for genital Chlamydia trachomatis and to evaluate the impact of screening in those participating.

DESIGN

An opportunistic screening programme (1 September 1999 to 31 August 2000) using urine samples, tested by ligase chain reaction (LCR). In-depth interviews were used for programme evaluation.

SETTING

Screening was offered in two health authorities at general practice, family planning, genitourinary medicine (GUM), adolescent sexual health, termination of pregnancy clinics and women's services in hospitals (antenatal, colposcopy, gynaecology and infertility clinics). Main participants: Sexually active women (16-24 years) attending for any reason.

MAIN OUTCOME MEASURES

Screening data: prevalence of infection by age and healthcare setting; proportion of positive patients attending for treatment. Evaluation data: participants' attitudes and views towards screening and follow up.

RESULTS

In total, 16 930 women (16-24 years) were screened. Prevalence was higher in younger women (16-20) than those aged 21-24 years and was highly variable at different healthcare settings (range 3.4%-17.6%). Prevalence was approximately 9% in general practice. The role of the project health advisers in managing results and coordinating treatment of positive individuals was essential; the vast majority of all positives were known to be treated. Women felt that screening was beneficial. Improving awareness and education about sexually transmitted infections is required to alleviate negative reactions associated with testing positive for infection.

CONCLUSIONS

Prevalence of infection outside GUM clinics is substantial and opportunistic screening using urine samples is an acceptable method of reaching individuals with infection who do not normally present at specialist clinics.

The genetic legacy of the Quaternary ice ages

Global climate has fluctuated greatly during the past three million years, leading to the recent major ice ages. An inescapable consequence for most living organisms is great changes in their distribution, which are expressed differently in boreal, temperate and tropical zones. Such range changes can be expected to have genetic consequences, and the advent of DNA technology provides most suitable markers to examine these. Several good data sets are now available, which provide tests of expectations, insights into species colonization and unexpected genetic subdivision and mixture of species. The genetic structure of human populations may be viewed in the same context. The present genetic structure of populations, species and communities has been mainly formed by Quaternary ice ages, and genetic, fossil and physical data combined can greatly help our understanding of how organisms were so affected.

Update on adolescent contraception

Recent advances in OCPs include less androgenic progestins and lower doses of ethinyl estradiol. All low-dose OCPs are safe in terms of venous thrombosis risk in appropriately chosen patients. DMPA is a safe and effective long-acting contraceptive agent; clinical attention should be directed to its most common side effect, irregular bleeding. DMPA does not seem to affect mood, and it is uncertain what impact it has on weight changes. More research needs to be conducted on its impact on adolescent bone metabolism. Norplant continues to be the only subdermal contraceptive implant marketed in the United States. It provides safe and effective contraception and has the best continuation rate of all types of hormonal contraception. Its most common side effect is irregular bleeding. Norplant may be especially well suited for adolescents who have recently been pregnant or who are not tolerating other types of contraception. Emergency postcoital contraception continues to be underused in the United States, with a lack of awareness among patients and clinicians. Mechanisms of action include a delay in ovulation and interference with implantation. Research and public health groups are striving to increase patient and provider awareness and use of emergency contraception.

Gene localization for an autosomal dominant familial periodic fever to 12p13

We report gene localization in a family with a benign autosomal dominant familial periodic fever (FPF) syndrome characterized by recurrent fever associated with abdominal pain. The clinical features are similar to the disorder previously described as familial Hibernian fever, and they differ from familial Mediterranean fever (FMF) in that FPF episodes usually do not respond to colchicine and FPF is not associated with amyloidosis. Frequent recombination with the marker D16S2622, <1 Mb from FMF, at 16p13.3, excluded allelism between these clinically similar conditions. Subsequently, a semiautomated genome search detected linkage of FMF to a cluster of markers at 12p13, with a multipoint LOD score of 6.14 at D12S356. If penetrance of 90% is assumed, the FPF gene maps to a 19-cM interval between D12S314 and D12S364; however, if complete penetrance is assumed, then FPF maps to a 9-cM region between D12S314 and D12S1695. This interval includes the dentatorubropallidoluysian atrophy locus, which, with FPF, gave a maximum two-point LOD score of 3.7 at a recombination fraction of 0. This is the first of the periodic-fever genes, other than FMF, to be mapped. Positional candidate genes may now be selected for mutation analysis to determine the molecular basis for FPF. Together with the recent identification of the defective gene in FMF, identification of a gene for FPF might provide new insights into the regulation of inflammatory responses.

Development of a national clinical logbook system for oral and maxillofacial surgery trainees--the RACDS, OMS system

The development of a national computer database for trainees' clinical logbooks is described. Data are collected contemporaneously by trainees under the supervision of the director of their training programme. The full scope of oral and maxillofacial surgery is covered, and a national standard of experience has been developed. The benefits of this system to individual trainees, training institutions, and national educational bodies are presented.

470 million years of conservation of microsatellite loci among fish species

Primers for 18 microsatellite loci originally isolated from whiting (Merlangius merlangus, n = 6), stickleback (Gasterosteus aculeatus, n = 5) and cod (Gadus morhua, n = 7) were tested across a panel of diverse fish species, representing the three principal superclasses and most principal superorders of fish, to examine conservation of microsatellite regions across distantly related taxa. Three methods were used. First, amplified fragments were analysed by Southern blotting using the relevant microsatellite motif probes. A total of 17 of the tested primer pairs gave a product in the expected size range in at least four of 11 tested species. Second, for two study loci the amplified polymerase chain reaction products were cloned and sequenced in five fish species to reveal a high level of conservation of the flanking and microsatellite sequences. Finally, the 17 loci successfully amplified in non-source species were tested for polymorphism in groups of unrelated individuals from nine species, in several cases revealing extensive polymorphism. Levels of polymorphism were generally high in species from which the loci were derived or among closely related species. The conservation of flanking sequences for particular microsatellite motifs over the span of fish evolution represented in the test species (470 million years) far exceeds that hitherto reported and lends support to the suggestion (derived from studies of whales and marine turtles) that the rate of base substitution in nuclear and mitochondrial sequences is lower in aquatic than terrestrial organisms. A further explanation could be that these sequences, although generally considered neutral, may play an important role in eukaryotic genomes, and may be under strong selective constraints. The study suggests that heterologous primers will be a ready source of polymorphic markers among fish species, but also indicates that caution should be used in cross-species comparisons of variability.

Mortality, endotoxaemia and cytokine expression after intermittent and continuous hepatic ischaemia

This study compared mortality rates, endotoxaemia, systemic tumour necrosis factor (TNF) and interleukin (IL)-6 concentrations after continuous and intermittent hepatic ischaemia. Two groups of rats were subjected to continuous or intermittent left hepatic inflow occlusion for a total period of 120 min in each group. Intermittent ischaemia was associated with significantly lower mortality rates than continuous ischaemia (four of 20 versus 15 of 20; P = 0.0015). In a separate study, again following 120 min continuous or intermittent ischaemia, systemic blood was sampled at 0 min, 1 h, 3 h and 5 h after final clamp release for measurement of endotoxin, TNF and IL-6 concentrations. Endotoxin concentrations were significantly lower at 1 h, as were TNF and IL-6 concentrations at 3 and 5 h, after final clamp release in the group having intermittent ischaemia (P < 0.05). Intermittent ischaemia is associated therefore with significantly reduced mortality rates and lower systemic endotoxin, TNF and IL-6 concentrations when compared with continuous ischaemia.

The effect of lateral asymmetries on breast feeding skills: can midwives' holding interventions overcome unilateral breast feeding problems

OBJECTIVE

to determine whether the three human lateral asymmetrical behaviours (maternal handedness, maternal preferred cradling side, neonatal preferred head turning) affected the development of a unilateral breast feeding problem (UBP).

DESIGN

quasi-experimental comparing 32 postnatal women who reported a UBP with 28 who did not.

SETTING

maternity unit in the south of England.

PARTICIPANTS

60 mother/baby pairs where it was the mother's first attempt at breast feeding, there were no structural abnormalities of the breasts or nipples, no obstetric abnormalities, and where the mother had had no more than 100 mg pethidine in labour. The babies had to be less than 72 hours old at recruitment, show no abnormal behaviour, such as floppiness or irritability, and weighed 2500 g or more.

MEASUREMENTS AND FINDINGS

handedness test, preferred cradling side established, neonatal preferred head turning established, demographic data. The two groups of women did not differ on demographic characteristics, but multiparous women were less likely to report a UBP or a neonatal preferred feeding side and more likely to be feeding at six weeks post delivery. Neither dominant handedness nor maternal preferred holding side alone were associated with a UBP but when the dominant hand was different from the preferred holding side, the women were more likely to have a problem side and to report a preferred feeding side. A neonatal head turning preference was associated with a UBP but not with success/failure of breast feeding at six weeks post-delivery. There were no associations between the holding interventions used by midwives and the successful continuation of breast feeding until six weeks post-delivery.

KEY CONCLUSIONS

there is no conclusive evidence associating the management of a UBP with differing intervention holds.

IMPLICATIONS FOR PRACTICE

there is a need of further research to select the most appropriate intervention to help an individual mother and baby.

Transperitoneal closure of the internal ring in incarcerated infantile inguinal hernias

Over a 6-year period, 14 infants with a total of 16 inguinal hernias (IH) underwent transperitoneal closure of the internal ring (TPIR). This was performed through a minilaparotomy, using a purse-string suture placed around the internal ring from within. A difficult inguinal dissection of an edematous and friable spermatic cord was avoided. TPIR was performed for incarceration in 13 of the infants and for recurrence of the hernia within 24 hours of herniotomy in one. There were no intraoperative problems, and during follow-up there was no evidence of testicular atrophy or recurrence of the hernia. This suggests that TPIR is a reliable and safe operation in babies for whom the alternative inguinal approach would be difficult. These situations include hernias that are irreducible and early recurrence in which dissection of the cord would risk damage to the vas deferens or testicular vessels.

Inguinal herniotomy in young infants, with emphasis on premature neonates

Over a period of 6 years, 251 infants under 6 months of age underwent repair of inguinal hernias (IH; n = 311). There were 241 males and 10 females. Incarceration occurred in 59 infants (24%), one of whom had bilateral incarceration. As a result of the authors' policy to operate on infantile IH within 7 days of diagnosis, only 6% of the incarcerations occurred in already diagnosed cases. Sedation and taxis did not reduce the hernia in 22 cases (38%); transperitoneal closure of the internal ring was performed in 14 of these. Eighty-nine infants (36%) were born premature; thirty-nine (41%) of these had been ventilated before, a possible cause of the hernia. Bilateral presentation was more common in the premature infants (35% v 17%); surprisingly, incarceration was less common (13% v 24%). Hence, the policy of delaying herniotomy until discharge from the neonatal unit was justified. During follow-up, six recurrences were noted and two cases of testicular atrophy.

Does vasectomy cause testicular cancer?

Between 1975 and 1990, 330 men developed testicular tumours in Northern Ireland. Their names were cross matched with a sample of 2904 men who had undergone vasectomy between 1970 and 1985. The expected numbers of tumours in vasectomised patients was 2, while the actual number was 1. Our experience does not indicate that vasectomy causes testicular cancer.

The clinical and endocrine assessment of three different antiandrogen regimens combined with a very long-acting gonadotrophin-releasing hormone analogue

Tumor flare is reported in up to 40% of patients treated with gonadotrophin-releasing hormone analogues for prostate cancer. In order to investigate the optimal way to eliminate tumor flare, we have treated patients with one of three different antiandrogen regimens used in combination with gonadotrophin-releasing hormone (GnRH) agonist. The early results of this study are presented here. Thirty patients with advanced symptomatic disease were randomized to receive either cyproterone acetate 50 or 100 mg three times daily or flutamide 250 mg three times daily given for 1 week before and during the first month of GnRH agonist treatment. The endocrine profiles of these patients were compared with those of historic controls treated with depot agonist alone. Three patients treated with low-dose cyproterone acetate and one with flutamide developed a transient exacerbation of their disease. No patients treated with the higher-dose cyproterone acetate regimen developed tumor flare. No patients treated with cyproterone acetate had an increase in serum testosterone above baseline following depot GnRH agonist implantation. All patients treated with flutamide had increases in serum testosterone, but this did not significantly increase further with implantation. This study suggests that all patients receiving GnRH agonist treatment should be pretreated with cyproterone acetate 100 mg three times daily for 1 week before implantation and for the first treatment month.

Cultivation of Tripterygium wilfordii Tissue Cultures for the Production of the Cytotoxic Diterpene Tripdiolide

The production of the cytotoxic agent tripdiolide employing plant tissue cultures of TRIPTERYGIUM WILFORDII is demonstrated. Detailed investigations of a developed cell line of T. WILFORDII in terms of tripdiolide production versus variations in growth conditions, for example media composition, are presented. Also the age and size of the inoculum and the incubation period with respect to tripdiolide formation are evaluated.