Buprenorphine for the treatment of perinatal opioid dependence: pharmacology and implications for antepartum, intrapartum, and postpartum care

Opioid dependence during pregnancy is associated with significant health risks for both the mother and her fetus. Opioid maintenance therapy with methadone (Dolophine) is the current standard of care, reduces medical and social risks associated with illicit drug use, and decreases rates of prematurity and low birth weight. However, treatment with methadone is frequently associated with neonatal abstinence syndrome. Buprenorphine is an alternative to methadone that preliminary data indicates is equivalent in safety and efficacy to methadone and significantly increases access to treatment. The pharmacology of buprenorphine and its implications for the care of pregnant women with opioid dependence are described.     

卵巢恶性肿瘤患者保留生育功能手术的指征及处理原则

年轻的卵巢恶性肿瘤患者施行保留生育功能手术应限于早期且组织学类型较好者,如高、中分化上皮性肿瘤而非透明细胞瘤。术后一般不影响预后,且妊娠结局良好。而对中、晚期患者一般不推荐施行保留生育功能手术。卵巢交界性肿瘤患者年龄相对较轻,而且在诊断时多为Ⅰ期肿瘤,施行保留生育功能手术后妊娠成功率甚高。对卵巢交界性肿瘤患者甚至可行卵巢囊肿剥除术,其并不影响预后。生殖细胞肿瘤患者行保留生育功能手术的文献报道多为无性细胞瘤,手术成功率较高。而对晚期或其他类型生殖细胞肿瘤患者也有尝试保留生育功能手术,但这仅为个案报道,通常并不推荐施行保留生育功能手术,除非患者及家属有强烈意愿。对于施行保留生育功能手术的卵巢恶性肿瘤患者,由于具体情况不同,手术应因人而异行个体化治疗。     

Past,present and future of primary systemic treatment in breast cancer

Primary systemic treatment is a fundamental part of breast cancer therapy, and it is applied to non-surgical and locally advanced tumours as well as surgical tumours to increase the likelihood of conservative treatment. Its aim is to achieve the best possible survival with better cosmetic results and with the lowest number of treatment-related secondary effects. Before treatment is started, it is necessary to attain the best knowledge of the biological features and locoregional extension of the tumour. To do so, it is necessary to obtain a biopsy of the lesion with a wide bore needle, as well as good radiological knowledge of the disease. Therefore, currently, the use of a dynamic magnetic resonance imaging (MRI) of the breast should be included in all cases. In addition, before it is started, especially in those tumours in which conservative treatment is considered, one or several radiopaque markers should be put into place to make it possible to locate the area to be treated if there is a considerable or complete response. Systemic treatment is mainly based on combined chemotherapy with anthracyclins and taxanes, in addition to some biological agents with demonstrated efficiency for increasing the likelihood of complete disease response (trastuzumab in patients with Her-2/neu overexpression). However, there is room for neoadjuvant hormone treatment, in patients with hormone receptor overexpression, especially in those cases in which chemotherapy is contraindicated as well as in elderly patients with a relatively short life expectancy. The assessment of preoperative treatment should be based on adequate radiological tests, and nowad these should include MRI before taking decisions about adequate surgical treatment. The objective of primary treatment is to be able to increase survival and improve the chances of local treatment in the case of locally advanced treatment, achieving results that are at least equal to those of adjuvant treatment in the case of surgical tumours, but with greater chances of conservative surgery. Although the objective is survival, achieving complete pathological response seems to be a reasonable related objective, although these are more closely linked in some tumour subtypes.     

Síndrome de Ogilvie: una complicación poscesárea

Ogilvie's syndrome is acute colonic pseudo-obstruction without mechanical obstruction, is a tipical complication of caesareas and hips surgery. It is difficult to diagnose, mainly, by having clinic similar to paralytic ileus, but with a much higher gravity. Its complications are ischemia and perforation, which can have when establishing a mortality rate of up to 50%. This is a case with bad evolution after caesarea and that despite the medical treatment is complicated with cecal perforation, finishing in a right hemicolectomy.     

Tumor de Brenner benigno asociado a tumor mucinoso borderline de ovario en paciente postmenopáusica

Brenner tumour is an uncommon neoplasm of the ovary of uncertain origin and often asymptomatic. Diagnostic is complex, without specific ultrasound patterns. It has been associated with mucinous tumours with different potential for malignancy, and it is possible to find malignant or borderline components that determine the treatment. For its differential diagnosis immunohistochemical study is essential, which shows, according to various studies, a clonal origin of Brenner and mucinous tumour. This is a case report of a Brenner tumour associated with a mucinous tumour, which in a definitive study showed to be associated with a borderline ovarian tumour component.     

Muerte materna por shock hemorrágico en gestante con síndrome de Ehlers-Danlos vascular tipo IV

Ehlers-Danlos syndrome is a very rare inherited connective tissue disorder associated with a mutation in the collagen gene. The diagnosis is mainly clinical, with subsequent confirmation by genetic study. It is divided into several types according to their clinical presentation, with symptoms that can range from skin manifestations, to vascular, digestive, neurological or joint disorders. Treatment is only symptomatic, requiring prophylactic management if surgery is needed; and genetic counselling for the study of first-degree relatives. It is considered a high-obstetric-risk disease, so close monitoring of the patient during pregnancy is required, with special attention to the mode of delivery, which must be agreed by a multidisciplinary team given the morbidity and mortality of this disease.     

Síndrome de insensibilidad a los andrógenos familiar

Androgen insensitivity syndrome is the most frequent of the sexual development disorders with 46,XY karyotype and female phenotype. This syndrome is due to a mutation in the androgen receptor gene, which lies on the X-chromosome. Diagnosis is usually made in childhood due to inguinal hernias or during puberty due to primary amenorrhea. Gonadal extirpation is required because of the risk of malignant transformation. We present a 25-year-old patient with primary amenorrhea diagnosed with androgen insensitivity syndrome, who reported four relatives with the same diagnosis.     

Laparoscopic myomectomy in 2007: state of the art

With fifteen years of development, laparoscopy for myomectomy has proven its advantages. However, this technique remains controversial concerning its feasibility and the quality of uterine scar obtained. Laparoscopic myomectomy (LM) is usually indicated when number of myomas is less than 3 to 4 with a 8 to 9 cm maximal size. Surgical technique is standardized and intervention time becomes acceptable. Risk of conversion ranges between 1 to 3% when technique is realized by trained surgeon. Bleeding is less important compared with laparotomy and immediate postoperative complications are exceptional. Results concerning fertility are positive with more than 50% of infertile patient conceiving after surgery, this rate rising up to 61 to 76% for myomas isolated cause for infertility; these values can be compared with myomectomy realized by laparotomy. Postoperative adhesions seem to be less important after laparoscopy when compared with laparotomy but this point needs to be confirmed. Risk of uterine rupture is estimated between 0 to 1%, but this point needs for larger series evaluation and needs to be compared with pregnancies after laparotomy. Laparoscopic myomectomy is a feasible technique, safe for patients waiting for conception and has proven its interest in case of infertility.     

What are the individual perceptions of patients with borderline tumours of the ovary in regard to pathogenesis and prognosis? A structured survey on 60 women

The traditional notion that a family is built around and based on blood or genetic ties is challenged when assisted human reproduction utilizing donor gametes is used. A focus on the family?–?in contrast to the individual?–?requires from medicine an extension of thinking in which a model that incorporates treating infertility and building a family becomes the norm. Such a model will require that attention is given to the psychological and social needs of the would-be parents, thus enabling them to approach their family building with confidence. This confidence is expected to carry through to their sharing with their offspring the nature of their family building and thus avoid the stigma that leads to secrecy. Research relating to dimensions of family building when donor insemination has been used is reviewed. The impact of professional attitudes, along with the policies adopted by governments concerning access to genetic information for offspring, significantly influences the families built with assistance of donor gametes or embryos. The evolution of professional thinking in this area is reviewed, along with the increasing involvement of governments.     

Person‐Centered Primary Care and Type 2 Diabetes: Beyond Blood Glucose Control

With an estimated 9% of persons in the United States diagnosed with diabetes, primary care providers such as midwives and nurse practitioners are increasingly working with persons who have diabetes and are seeking primary care services. This article reviews the current literature with regard to the initial evaluation of individuals who are diagnosed with diabetes, and what is entailed in comprehensive continuing management of care. A person‐centered interprofessional approach to care of the person with diabetes is presented. Recommendations are given that address dietary habits, activities of daily living, medication regimens, and potential alternative therapies. Social constructs related to effective care of individuals with diabetes also are addressed. Knowledge of current research that has identified effective care practices for individuals with diabetes is imperative to ensuring their well‐being, and promoting a person‐centered and interprofessional approach is best for offering optimal care to those diagnosed with diabetes.     

Drug-induced pineal gigantism in rabbits as a tool to study the pineal—gonadal interaction

The combination of the Mayer—Rokitansky—Küster (MRK) syndrome with renal anomalies is well known (incidence: 36%). The combination with skeletal anomalies is also known (incidence: 10%). However, the coincidence with ear anomalies is rare, and the coincidence with facial anomalies is extremely rare. The combination of the MRK syndrome with renal, skeletal, ear and facial anomalies is described in a case report with a review of the literature. It is not only worthwhile to be alert for urinary tract anomalies in patients with the MRK syndrome, but also to study the skeletal and auditory systems in these patients.     

Medical Abortion

Objective: to review medical abortion with emphasis on studies using methotrexate and misoprostol.Data Sources: a MEDLINE search and bibliographies from relevant articles were used. Only studies in English and French with medical abortion using mifepristone, methotrexate and misoprostol were reviewed.Data selection: only studies using mifepristone with 100 or more women were included. All studies using methotrexate and misoprostol alone or in combination were reviewed.Results: in early pregnancy, combinations of mifepristone with prostaglandin or methotrexate with misoprostol are effective for pregnancy termination. When misoprostol is used to augment mifepristone or methotrexate, its vaginal application appears to be superior to the oral route. Vaginal misoprostol (800 μg) is more effective applied five to seven days after the methotrexate than three days after. For inevitable or incomplete abortions, misoprostol alone may be used effectively to avoid surgery. When surgical abortion fails, medical abortion is an excellent back-up treatment.Conclusion: medical abortion with mifepristone or methotrexate plus misoprostol is a safe and effective method of pregnancy termination. Because the complete abortion rate with medical abortion is less than with vacuum aspiration, surgery cannot be completely avoided. Commitment on behalf of both physician and patient is necessary to ensure safety. If mifepristone becomes available in Canada, studies comparing its use to methotrexate will be of paramount importance to help to determine the best method. Further research into medical abortion is important to women’s health as this method is highly acceptable and has the potential to increase access to safe abortion.     

Robotic surgery in gynaecology

Gynaecological surgery is rapidly changing with innovations in technology and minimally invasive surgery is now the main route of operating in pelvis. This is associated with improved perioperative outcomes especially length of stay and readmissions leading to early recovery as compared to open procedure. Open hysterectomy is still undertaken in many parts of the world due to complex pathology with higher conversion rates with laparoscopy as complexity increases. Innovations in minimally invasive surgery with development of wristed computerized surgical tools has led to implementation of robotic surgery in healthcare. Robotic surgery is very intuitive and precise with improved ergonomics and ability for surgeon to control the camera and utilized extra arms for manipulation. The limitation of wider use of this latest technology is due to higher capital cost of the equipment. However, with full healthcare economic analysis and competition between numerous platforms will make robotic surgery the method of choice especially for patients with complex pelvic pathology. There is need for surgeons and surgical team to obtain training in both technical and non-technical aspects of a procedure. Training is best done within a standardized curriculum and implementation of robotic surgery should be within clinical governance framework.     

妊娠合并骨外尤因肉瘤治疗后复发转移成功分娩一例

妊娠合并骨外尤因肉瘤（extraskeletal Ewing sarcoma）在临床上十分罕见,复发、转移率极高,目前尚无统一有效的治疗方案。报告1例妊娠合并腹膜后骨外尤因肉瘤,因腰骶部疼痛就诊,既往接受腹膜后骨外尤因肉瘤肿瘤切除术联合左肾切除术,并辅以术后化疗,结合相关病史及检查考虑骨外尤因肉瘤复发、转移,于兰州大学第一医院顺利剖宫产一名健康足月活女婴。由于妊娠合并骨外尤因肉瘤十分罕见,治疗更加困难且预后欠佳,建议临床工作中应对可疑妊娠妇女在定期产检基础上加强随访,及时发现病灶。一旦确诊,需在多学科的共同管理模式下制定治疗策略,以帮助患者克服妊娠期癌症带来的困难,尽可能减少不良结局。     

Obstructed Hemivagina with Ipsilateral Renal Anomaly

The association of obstructed hemivagina with ipisilateral renal anomaly (OHVIRA) is a well-described entity. While there has been an increased familiarity with this disorder, the exact incidence of OHVIRA is unknown. Our aim was to review the available literature on this topic, look at common presentations, and uncommon presentations. This condition is a well-described entity but requires careful evaluation, because unique presentations do occur. Diagnostic challenges include time of presentation and symptoms associated with presentation. Surgical challenges include microperforation of the hemivaginal septum, pelvic inflammatory disease, thick septum, or high septum. Each of these must be managed carefully. Although a solitary kidney is frequently thought to be associated with OHVIRA, dysplastic kidneys, pelvic kidneys, or ectopic ureters can occur. Prompt and accurate diagnosis is essential for relief of symptoms and prevention of complications. To minimize problems associated with delayed diagnosis, magnetic resonance imaging evaluation is recommended along with referral to a center with expertise in these conditions.     

妊娠合并宫颈癌一例

妊娠合并宫颈癌较为罕见,早期临床表现并不典型。由于缺乏妇科肿瘤筛查意识,易与胎膜早破、先兆早产等疾病相混淆,导致治疗延误。妊娠合并宫颈癌的治疗尚无成熟且规范的方案,尤其是妊娠中期宫颈癌的治疗存在很大争议,需要根据病理检查、分期、胎儿发育情况及孕妇的妊娠期望等制定个体化综合治疗方案。回顾性分析1例以阴道流血流液入院,经保守治疗失败后,行剖宫产术终止妊娠的中期妊娠合并宫颈癌的诊治经过,并对相关文献进行复习,以期为疾病的诊治提供经验。     

Contrast Ultrasonography for Tubal Patency

Evaluation of tubal patency is an essential part of a fertility workup. Laparoscopy with chromopertubation in conjunction with hysteroscopy is the gold standard in evaluation of tubal patency and the uterine cavity. In this review article we describe a newer method for evaluation of the uterus and fallopian tubes, that is, hysterosalpingo–contrast sonography (HyCoSy). Accuracy of HyCoSy for tubal patency has been shown to be comparable to that with hysterosalpingography (HSG) when compared with laparoscopic chromopertubation. Sensitivity ranges from 75% to 96%, and specificity from 67% to 100%. HyCoSy is also accurate when compared with HSG in determining tubal occlusion after hysteroscopic sterilization, with 88% of patients stating they would prefer to undergo the tubal occlusion test in their gynecologist's office. Because HyCoSy also includes evaluation of the uterine cavity with saline solution–enhanced sonohysterography, accuracy in evaluating the uterine cavity is >90% when compared with hysteroscopy. HyCoSy enables the gynecologist to complete a fertility workup in the office in the most minimally invasive way. HyCoSy is well tolerated and has been suggested in the literature to replace HSG for evaluation of tubal disease in the subfertile population.     

Obesity and menstrual disorders

Obesity is a growing public health concern and is associated with a range of menstrual disorders, including heavy menstrual bleeding, oligomenorrhea, dysmenorrhea, and endometrial pathology. Investigations may be more logistically challenging in those in the population with obesity, and because of the heightened risk of endometrial malignancy, there should be a low threshold for biopsy to exclude endometrial hyperplasia. Although treatment modalities for women with obesity are broadly similar to those with a normal BMI, additional consideration must be given to the risks associated with estrogen in obesity. Outpatient management of heavy menstrual bleeding is a developing field and outpatient treatment modalities are preferable in the population with obesity to avoid the morbidity associated with anesthetics.     

卵巢硬化性间质瘤的研究进展

卵巢硬化性间质瘤是一种临床罕见的卵巢良性肿瘤，其发病率低，病因不明确，以年轻女性多见，多为单侧肿块，常因月经不规则出血或体检发现腹部包块而就诊。影像学检查可见“湖岛征”、“快进慢出”和“向心性强化”等改变。病理组织学见单侧类圆形囊实性肿块，“假小叶”为特征性病变。免疫组织化学可见抑制素、波形蛋白和肌动蛋白等阳性表达。确诊主要通过病理组织学诊断，影像学检查具有重要参考价值。术前诊断困难，容易与卵巢纤维瘤、卵泡膜细胞瘤、卵巢库肯勃瘤和颗粒细胞瘤等相混淆。手术治疗为主要治疗手段，多采用患侧肿瘤切除术或附件切除术，术后预后较好，卵巢功能可恢复正常。对于肿瘤细胞出现核分裂象和坏死较多时，需警惕复发风险，建议长期跟踪随访。     

Choosing Wisely: Bedrest—A Panacea for All That Ails the Gravida?

Bedrest has been frequently prescribed for various high-risk conditions during pregnancy. A common indication cited is concern regarding increased risk of spontaneous preterm birth, known to be associated with gestations with twins or higher-order multiples, polyhydramnios, presence of preterm contractions with or without evidence of cervical change, sonographic cervical shortening, presence of a dilated cervix with bulging membranes, or preterm premature rupture of membranes. In some cases, there is concern that excessive movement may increase the risk of antepartum hemorrhage, as may be with placenta previa, with or without a higher risk of a morbidly adherent placenta or a vasa previa. It is also thought that improved splanchnic perfusion with bedrest may enhance blood supply to the uterus with possible benefit in conditions such as preeclampsia (or gestational hypertension) or fetal growth restriction. However, there is no evidence of any benefit of bedrest or reduced activity during pregnancy for either of these conditions. On the contrary, there is evidence of harm, in addition to the fact that exercise is known to be beneficial in pregnancy.