Iliac atherosclerotic occlusive disease complicating radiation therapy for cervix cancer: a case series

BACKGROUND: Diagnosis and management of atherosclerotic occlusive disease complicating radiation therapy for squamous carcinoma of the cervix (SCC) are not well known. CASES: A series of four patients who underwent medical or surgical treatment of radiation-induced artery disease were identified. Chronic right iliac artery occlusion was seen in one patient 7 years after external irradiation for SCC and was treated by a femorofemoral bypass. Acute arterial occlusion was seen in three patients. One patient developed right foot ischemia 2 years after external irradiation for SCC which was treated by a right axillofemoral bypass. One patient developed a left toe necrosis 2 years after external irradiation for a recurrence of SCC which was treated by a percutaneous artery dilatation. One patient developed, 3 years after external irradiation for SCC, a subacute ischemia of the left leg on the first postoperative day after a rectal resection. It was treated by vasodilators, calcium inhibitors, and anticoagulants. CONCLUSIONS: Diagnosis of radiation-induced atherosclerotic occlusive disease complicating radiation therapy for SCC is easy but treatment is difficult. Long-term results of arterial dilatation are limited and extraanatomic bypass with allograft is the treatment of choice whenever feasible. However, because of poor long-term results, surgery should be attempted only in the case of severe ischemia.     

The use of topical nitroglycerin ointment to treat peripheral tissue ischemia secondary to arterial line complications in neonates.

Catheterization of the aorta through the umbilical artery and/or of peripheral arteries in neonates may be accompanied by a number of complications, of which thrombotic phenomena and peripheral vasospasm are the most common. Two neonates with peripheral ischemia caused by vasospasm from indwelling umbilical artery catheterization and one infant with left hand ischemia due to a left radial artery line were successfully treated with 2% nitroglycerin ointment. No adverse effects were noted.     

Fundamental studies on arterial infusion chemotherapy for cervical cancer--with reference to the histological finding in infiltrating cancer and localization of the drugs in tissues

Preoperative arterial infusion of peplomycin was carried out on 15 cases of Stage I or II cancer of the cervix, and the value of arterial infusion chemotherapy with peplomycin and its efficacy as a preoperative therapy in cervical cancer were evaluated by analysis of (1) histological changes, (2) localization of the drug in tissue, and (3) tissue concentration of the drug in the completely resected tissues, with the following results: The chief histological change was a regression of cancer nests accompanied by degeneration and necrosis of cancer cells. This change was clearer at the head of infiltrating cancers than at their superficial layer or center. Peplomycin was localized with high activity at the disintegrated part of cancer nests, i.e., its activity was closely correlated to the severity of histological change. Time-course changes in its localization suggested the vessel wall----stroma----cancer as the route of its transport. The tissue concentration of peplomycin was maintained high over a long time. Particularly in the portio vaginalis, the time course decline of the concentration was gentle. From the above findings, arterial infusion of peplomycin was considered to be an effective method of chemotherapy for cervical cancer, and worth being tried as a preoperative therapy too.     

Diffuse and severe ischemic injury of the extremities: a complication of umbilical vein catheterization

We report a case of severe, peripheral, and diffuse tissue ischemia after umbilical vein catheterization (UVC) in a preterm newborn born to a preeclamptic mother. Nitroglycerin ointment was used to treat lesions. The recovery was good but partial loss of the distal phalange of one finger and one toe occurred. This is the first report of peripheral vasospasm occurring after UVC. Topical nitroglycerin, traditionally used to treat peripheral artery catheter-induced ischemic injury, may be useful to treat the same lesions occurring after UVC.     

Penile Prosthesis Implantation in Patients with a History of Total Phallic Construction

IntroductionOutcomes following penile prosthesis implantation in patients with a history of total phallic construction are not well described.AimThe aim of this study was to evaluate outcomes following neophallus penile prosthesis placement.MethodsRetrospective review penile prosthesis placement in patients with prior total phallic construction. GORE-TEX® (Gore Medical, Flagstaff, AZ) sleeve neotunica construction was utilized in all patients.Main Outcome MeasureSuccess defined as patient sexual activity with a functioning prosthesis.ResultsThirty-one patients underwent neophallic prosthesis implantation at a mean 35.6 years of age. Prosthesis placement occurred at an average 56.3 months following phallic construction and follow-up was a mean of 59.7 months. Malleable prostheses were placed in 21 patients and inflatable in 10; implants were bilateral in 94%. Six percent experienced operative complications including a bladder injury (1) and phallic flap arterial injury (1). Postoperative complications occurred in 23% at a median 5.5 months following placement. Five prostheses were explanted secondary to infection or erosion and two additional required revisions. Of the explanted prosthesis two were later replaced without further complication. Eighty-one percent of patients were sexually active following prosthesis placement.ConclusionsPenile prosthesis placement is possible in patients with prior penile reconstruction/phallic construction. Although complications rates appear to be elevated in this population compared with historic controls of normal anatomic men, the majority of patients in this series were sexually active following prosthesis placement. This demonstrates the utility of prosthesis implantation in these difficult patients.     

Successful management of vulvar adhesions with potent topical corticosteroids: a case report

BACKGROUND: Vulvar adhesions are a rarely reported but clinically recognized complication of severe ulcerations following herpes genitalis. The condition is avoidable with adequate pharmacologic treatment, hygiene, separation of the labia and topical application of skin emollients. CASE: Vulvar agglutination was diagnosed in a 23-year-old woman following hospitalization for severe herpetic vulvar ulcerations. Manual attempts to separate the labia under local anesthesia were unsuccessful. Topical application of a potent cortico- steroid led to separation with no residual effects. CONCLUSION: Preventive and proactive management of extensive herpetic vulvar ulcerations should be the first line of care. There will always be patients who will present at a later stage of the disease, with established vulvar agglutination; there potent topical corticosteriods could prove valuable. There is no literature on the use of topical corticosteroids as the primary treatment for vulvar adhesions, and further studies are essential.     

Successful use of topical nitroglycerine in ischaemia associated with umbilical arterial line in a neonate.

Ischaemic changes associated with umbilical arterial cannulation is an important cause of neonatal morbidity in the NICU. We report successful use of topical nitroglycerine in an infant with ischaemic changes over the right buttock following insertion of an umbilical arterial catheter.     

The influence of transdermal nitroglycerin patches on fetal blood flow parameters in threatened preterm labor

OBJECTIVES: The aim of our study was the assessment of fetal arterial Doppler parameters (umbilical artery and middle cerebral artery) in threatened preterm labor in the course of transdermal nitroglycerin therapy. MATERIALS AND METHODS: 16 pregnant women in between 27th and 34th week of gestation with symptoms of threatening preterm labor were brought into our study. Patients were treated with transdermal nitroglycerin (5 mg) patches. Maternal blood pressure. Manning's test score and fetal arterial Doppler blood flow were measured. RESULTS: Whereas maternal systolic blood pressure does not vary in the course of therapy, significant decrease in diastolic blood pressure was noted. There was no change in the mean umbilical and middle cerebral artery blood flow in the course of treatment. CONCLUSIONS: Nitroglycerin in the form of transdermal therapeutic system releasing nitric oxide doesn't effect fetal artery Doppler parameters. Nitroglycerin may be used as a safe therapeutic agent in treatment of preterm labor.     

Necrotizing fasciitis of the perineum secondary to a surgical treatment of Bartholin's gland abscess

Necrotizing fasciitis of the perineum is a rare but of fast evolution, and potentially fatal infectious disease process. It is characterized by progressive inflammation and extensive necrosis of subcutaneous tissue involving the fascia and other adjacent tissues. This infection may be idiopathic or secondary to local trauma or pelvic surgery. Its mortality rate is 20%. We report a case of necrotzing fasciitis of the perineum in a 34-year-old woman following incision and drainage of Bartholin's gland abscess. Streptococcus A, Proteus mirabilis, Escherichia coli, and Candida albicans were isolated. Intravenous broad spectrum antibiotic therapy was promptly instituted. Concurrent surgical debridement of all necrotic areas was required. Post debridement therapy required a long period of dressing changes until cicatrisation. Necrotizing fasciitis of the perineum is a surgical emergency. Early diagnosis and prompt aggressive debridement are the keys to successful management.     

The FORKO mouse as a genetic model for exploring estrogen replacement therapy

OBJECTIVE: To evaluate how chronically estrogen deficient female FORKO mice with genetic disruption of the FSH receptor respond to estrogen therapy. STUDY DESIGN: Subcutaneous estrogen agonist or antagonist therapy was initiated to study reproductive tissue response, adipose tissue mass and plasma lipid profiles. RESULTS: Within 36-48 hours of agonist administration, the classic measures of estrogenic activity were evident in the uterus and vagina. Older animals also responded to therapy during a 10-day period, indicating that estrogen receptor signaling systems are unaffected by aging. In these obese mutants, this short treatment decreased adipose tissue in all areas and corrected lipid abnormalities. Tamoxifen, a nonsteroidal mixed estrogen agonist and antagonist, had marginal effects on the uterus and body fat of FORKO mice, indicating differences in interaction. CONCLUSION: In FORKO mice lacking ovarian estrogen, the receptors remain fully functional. Hence, this is a useful model for studying estrogen replacement therapy and helps resolve questions related to efficacy and actions.     

Role of intravenous nitroglycerin in the treatment of severe pregnancy-induced hypertension complicated by pulmonary edema

Intravenous nitroglycerin would appear to be an ideal agent for the treatment of severe pregnancy-induced hypertension complicated by cardiogenic pulmonary edema. Nitroglycerin infusion effectively reduces preload by venous dilatation and, at higher doses, results in arterial vasodilatation. Because of these pharmacologic properties, the effects of intravenous nitroglycerin were studied in three patients with severe pregnancy-induced hypertension complicated by pulmonary edema. The major cardiovascular effects of nitroglycerin were to reduce the mean pulmonary capillary wedge pressure from 27 +/- 4 to 14 +/- 6 mm Hg, which result in a change in the colloid osmotic pressure to pulmonary capillary wedge pressure gradient from -10 to 2 mm Hg. No significant changes occurred in heart rate, central venous pressure, or cardiac index. Analysis of oxygen-related parameters revealed a significant (p less than 0.05) increase in oxygen delivery and extraction accompanied by a 53% increase in oxygen consumption. The changes in oxygen-related variables appeared to be secondary to a fall in mixed venous oxygen tension from 39 +/- 4 to 33 +/- 1 torr. These changes occurred without any significant improvement in arterial oxygen tension. We conclude that while intravenous nitroglycerin expeditiously corrects the hydrostatic derangements of pulmonary edema seen in pregnancy-induced hypertension, a rapid improvement in arterial oxygenation does not occur.     

Methemoglobinemia induced by topical vaginal sulfanilamide cream in a patient with cervical cancer: a case report

BACKGROUND: Methemoglobinemia is a rare disorder most commonly associated with the ingestion or topical application of an offending exogenous agent. The clinical consequences of acute methemoglobinemia can be devastating and include lethargy, headache, and dyspnea and, as methemoglobin concentrations rise, respiratory depression, confusion, seizures, and even death. CASE: Here we present a case of acute methemoglobinemia induced by exposure to topical vaginal sulfanilamide cream in a 36-year-old woman with a FIGO stage IIIB squamous cell cervical carcinoma. CONCLUSION: Although methemoglobinemia associated with topical anesthetics has been well documented, to our knowledge this is the first reported case of methemoglobinemia induced by exposure to topical sulfanilamide cream. Although patients undergoing intracavitary radiation treatment for cervical cancer are at risk for cyanosis due to the development of deep vein thromboses and pulmonary embolism, methemoglobinemia should be suspected in the setting of acute cyanosis with a normal arterial oxygen pressure.     

Estrogen treatment success in recurrent and persistent labial agglutination

STUDY OBJECTIVE: To estimate the success rate of conservative medical management and indications for surgery in cases of recurrent and/or persistent labial agglutination. DESIGN: A retrospective chart review was performed of girls treated for labial agglutination between 1996 and 2004. Records were reviewed for age, length of time of symptoms, previous treatments, results of topical estrogen therapy, and indications for surgery. SETTING: The study was performed in a tertiary care teaching university hospital. PARTICIPANTS: Charts of 67 girls with labial agglutination who were treated at the pediatric and adolescent gynecology clinic between 1996 and 2004 were reviewed. The average age was 4.1 years (range 0.6-14 years). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Improvement of persistent or recurrent agglutination labial agglutination with estrogen. RESULTS: Out of the 67 charts reviewed, 48 had recurrent or persistent disease. Within those 48 girls, initial treatments included: topical estrogen in 40 (83%), oral and topical estrogen in 1 (2%), topical estrogen in addition to manual separation in 5 (10%), and treated with manual separation alone in 2 (4%). Five girls were immediately treated surgically due to urinary problems or parents declining further topical treatment. Forty-three were treated with topical estrogen therapy with the following results: 15 opened either partially or completely, 9 required surgery, and 19 did not follow up. In the subset of girls with prior manual separation, 2 had resolution of adhesions with estrogen, 3 required surgery, and 2 had no follow-up. CONCLUSION: This study suggests that re-treatment of persistent or recurrent labial agglutination with topical estrogen therapy following detailed application instruction leads to avoidance of surgical intervention in at least 35% of cases. Even in cases which previously required manual separation, an attempt at conservative medical management may be considered.     

Untangling a web: an unusual case of labial necrosis in an adolescent female

BackgroundHair tourniquets are commonly described in the pediatric literature. Prompt recognition of a hair tourniquet and treatment with complete removal of the hair by pediatricians, pediatric emergency room physicians, or gynecologists is essential to prevent ischemia and necrosis of affected tissue.CaseHerein we present the case of a 12-year-old female referred to the pediatric surgery clinic for labial pain and swelling. She was found to have a hair tourniquet of the labia minora caused by pubic hair. The patient was taken to the operating room for examination under anesthesia and removal of the hair. Her post-operative course was unremarkable and she was discharged home the following day. On follow-up visit to the clinic her labial edema had completely resolved and she was pain free.Summary and ConclusionsUnlike previous case reports that describe hair tourniquets as originating from hair on the head, our patient had a hair tourniquet caused by pubic hair. In adolescents where personal hygiene of the perineum is difficult, clinicians need to be aware of the possibility of a hair tourniquet forming from pubic hair.     

Phentolamine use in a neonate for the prevention of dermal necrosis caused by dopamine: a case report.

Skin ischemia, necrosis, and gangrene are uncommon but known complications of dopamine extravasation. In most cases, these complications are associated with the use of high-dosage dopamine infusion. Subcutaneous phentolamine has been used as a therapeutic agent for these complications. However, this is the report of the first neonatal case report in the English literature of prompt reversal of imminent dermal ischemia and necrosis associated with low-dose dopamine infusion using subcutaneous phentolamine.     

Pelvic radiation necrosis and osteomyelitis following chemoradiation for advanced stage vulvar and cervical carcinoma

BACKGROUND: The treatment regimen indicated for most advanced stage vulvar, vaginal, and cervical cancer usually involves adjuvant chemoradiation therapy. Although the risk of complications is low, there have been reported cases of radiation necrosis and osteomyelitis following treatment for vulvar, vaginal, and cervical cancer. CASES: We present a vulvar cancer patient and a cervical cancer patient, both of whom were treated with radical surgery and postoperative chemoradiation. Following therapy, they were afflicted with pelvic radiation necrosis and osteomyelitis. The patients underwent surgery to resect the necrotic bone tissue and long-term antibiotic therapy to treat their osteomyelitis. They have since recovered and are followed closely by their gynecologic oncology and infectious disease physicians. CONCLUSION: The radiotherapy utilized to treat advanced stage gynecologic cancer can cause intestinal, vaginal, and urologic complications from micro-vascular damage to the organs. Pelvic bone osteonecrosis is a rare but disabling complication of pelvic radiation. Fortunately, with aggressive therapy, these patients may do well clinically.     

Cardiovascular alterations in severe pregnancy-induced hypertension: effects of intravenous nitroglycerin coupled with blood volume expansion

Control of blood pressure in severe pregnancy-induced hypertension has often relied on agents with an unpredictable onset and duration of action. Because intravenous nitroglycerin is a potent, rapidly acting agent with a hemodynamic half-life measured in minutes, we evaluated its cardiovascular effects with and without volume expansion in six patients with severe pregnancy-induced hypertension. Nitroglycerin alone reduced mean arterial pressure by 27.5% without any significant changes in heart rate, central venous pressure, or stroke volume. The pulmonary capillary wedge pressure fell from 9 +/- 3 to 4 +/- 2 mm Hg (p less than 0.05) while the cardiac index decreased from 3.51 +/- 0.67 to 2.87 +/- 0.76 L/min X m2. Oxygen delivery fell significantly (p less than 0.05), from 617 +/- 78 to 491 +/- 106 ml/min X m2. While volume expansion alone had no effect on mean arterial pressure, the combination of blood volume expansion and nitroglycerin resulted in a marked resistance to the hypotensive effect of nitroglycerin. Cardiac index, pulmonary capillary wedge pressure, and oxygen utilization were not significantly different from baseline values when volume expansion preceded nitroglycerin. We conclude that the ease with which nitroglycerin reduces blood pressure is dependent on the individual patient's volume status. Although volume expansion allows one to maintain cardiac index, pulmonary capillary wedge pressure, and oxygen utilization when used in combination with nitroglycerin, this benefit may be offset by a concomitant reduction in hypotensive capability.     

Thrombosis of the iliac artery in a premature neonate: thrombolytic therapy using rt-PA

Thromboembolic events in neonates are very rare. They are often associated with severe disease affecting the newborn or are secondary to central venous lines or arterial catheters. Most of the described cases of thromboses of the iliac or femoral arteries are associated with cardiac catheterisation or femoral invasive blood pressure monitoring. The relationship between single umbilical arteries and an increased incidence of structural and chromosomal anomalies is well known, but a higher rate of thromboembolic disease in infants with single umbilical arteries has not been described. Rt-PA (recombinant tissue plasminogen activator) has been successfully used in small studies and numerous case reports. To date controlled clinical trials giving guidelines for antithrombotic therapy using rt-PA are still lacking. We report the clinical course of a 700 g premature male, who was born by Caesarean section at 29 + 6 gestational weeks. On the fifth day the baby suffered from arterial thrombosis of the right pelvis axis. Antenatally a single umbilical artery was identified. Iliac arteries on the involved site appeared hypoplastic. Additionally, the prothrombin G20210A mutation was found. The patient was treated successfully using recombinant tissue plasminogen activator. In the case of a high risk of limb or organ loss due to arterial thrombosis, thrombolysis using rt-PA is justified. Appropriate rt-PA treatment has been studied for the adult but not the paediatric population. Hence, well-designed clinical trials are necessary to determine the pharmacokinetics and dynamics of thrombolytic agents in children.     

Analgesia for colposcopy: double-masked, randomized comparison of ibuprofen and benzocaine gel

OBJECTIVE: To evaluate pain relief effectiveness of oral ibuprofen and topical benzocaine gel during colposcopy. METHODS: In a double-masked, randomized controlled trial, women who attended a family medicine colposcopy clinic received one of four treatments, 800 mg of oral ibuprofen, 20% topical benzocaine, both, or placebos. Using visual analog scales, women recorded their pain after speculum placement, endocervical curettage (ECC), and cervical biopsy. Participants were 18-55 years old, spoke English, and were not taking other pain or psychotropic medications. Demographic and historical information was collected from each participant. RESULTS: Ninety-nine subjects participated. Twenty-five received oral ibuprofen and topical benzocaine (median pain scores on a 10-point scale for speculum placement, ECC, and biopsy were 0.75, 3.00, and 3.38, respectively), 24 received oral placebo and topical benzocaine (1.00, 3.75, and 2.63), 24 received oral ibuprofen and topical placebo (0.63, 3.75, and 2.25), and 26 received oral and topical placebos (0.75, 3.50, and 3.00). There were no statistically significant differences in patient visual analogue pain scale scores across the four groups (statistical power, ECC = 0.74, cervical biopsy = 0.62). Younger women and women who had pain with speculum placement were more likely to have increased pain during ECC. Increased pain during biopsy was associated with history of severe dysmenorrhea but no other demographic or historical factors. Women overall reported ECC and biopsy to be mildly painful, with median scores of 3.5 for ECC and 2.75 for biopsy on a 10-point scale. The range in pain scores was large, with some women reporting severe pain (for ECC minimum = 0.25, maximum = 10.0; biopsy: minimum = 0.0, maximum = 9.0). CONCLUSION: Colposcopy is perceived as somewhat painful, but oral ibuprofen and topical benzocaine gel, alone or together, provided no advantage over placebo in decreasing colposcopy pain.