Sonographic assessment of pregnancy co-existing with uterine leiomyoma in Owerri,Nigeria

Background

Uterine myomas co-existing with pregnancy could cause obstetric complications.

Objectives

To assess sonographically the frequency of occurrence and effect of uterine myomas co-existing with pregnancy.

Methods

A longitudinal study was conducted during a period of 23 months. A convenience sample of 816 consecutive consenting pregnant women who met the inclusion criteria was evaluated during routine prenatal ultrasound scan. The women were referred for prenatal sonography. One hundred of the subjects who had myoma co-existing with pregnancy and another 100 subjects without myoma were selected for follow-up. These groups were followed up till delivery and obstetric complications and outcomes were documented. Any changes in size and growth rate of myoma were documented.

Results

Subjects with myoma co-existing with pregnancy were 12.3%. This was commoner with increasing maternal age. An increase was observed in myoma mean size from 60mm to 63mm from the 1^st scan sequence to the 2^nd scan sequence and a reduction from 63mm to 59mm in the 3^rd scan sequence. Myoma growth rate was 0.667mm per week. Myomas in pregnancy especially large ones caused more complications during delivery when compared to pregnancies without myomas.

Conclusion

Routine sonography is important in pregnancy management of uterine myomas co-existing with pregnancy.     

Steam inhalation therapy: severe scalds as an adverse side effect

Background

Steam inhalation therapy is often recommended in the treatment of a common cold. However, it has no proven benefit and may in fact have serious adverse side effects in terms of burn injuries.

Aim

To quantify the human and economic costs of steam inhalation therapy in terms of burn injury.

Design and setting

A prospective database study of all patients admitted to the burn centres (Beverwijk, Groningen, Rotterdam) and the hospital emergency departments in the Netherlands.

Method

Number and extent of burn injuries as a result of steam inhalation therapy were analysed, as well as an approximation made of the direct costs for their medical treatment.

Results

Annually, on average three people are admitted to in one of the Dutch burn centres for burns resulting from steam inhalation therapy. Most victims were children, and they needed skin grafting more often than adults. The total direct medical costs for burn centre and emergency department treatment were €115 500 (£93 000), emotional costs are not reflected.

Conclusion

As steam inhalation therapy has no proven benefit and the number and extent of complications of this therapy in terms of burn injury are significant, especially in children, steam inhalation therapy should be considered a dangerous procedure and not recommended anymore in professional guidelines and patient brochures.     

A Long-Term Treatment Outcome of Abdominal Sacrocolpopexy

Purpose

The aim of this study was to evaluate the long-term treatment outcome and major complication rates of abdominal sacrocolpopexy (ASC).

Materials and Methods

This retrospective study included 57 Korean women who underwent ASC with mesh for symptomatic uterine or vault prolapse and attended follow-up visits for at least 5 years. Forty-seven women with urodynamic stress incontinence concomitantly received a modified Burch colposuspension. The long-term anatomical and functional outcomes and complication rates were assessed.

Results

The median follow-up was 66 months (range 60-108). Overall anatomical success rates (no recurrence of any prolapse ≥ stage II according to the pelvic organ prolapse-quantification system) were 86.0%. Urinary urgency and voiding dysfunction were significantly improved after surgery, however, recurrent stress urinary incontinence developed in 44.7% (21/47) of cases and half of them developed within 1-3 months post-op. Bowel function (constipation and fecal incontinence) and sexual function (sexual activity and dyspareunia) did not significantly change after surgery. Major complication requiring reoperation or intensive care developed in 12 (21.0%) cases.

Conclusions

ASC provides durable pelvic support, however, it may be ineffective for alleviating pelvic floor dysfunction except for urinary urgency and voiding dysfunction, and it contains major complication risk that cannot be overlooked.     

Uterine Leiomyomata in South Western Nigeria: a clinical study of presentations and management outcome

Background

Uterine leiomyoma is remarkably common, however only a subset of women have their fibroids clinically detected, symptomatic, or warrant surgical treatment. Its removal is commonly associated with complications. To prevent or control the occurrence of this complication requires the understanding of the factors associated with the complications.

Objective

To evaluate the sociodemographic, clinical characteristics, management outcome and its determinants in southwestern Nigeria.

Methods

Study was carried out at two large tertiary hospitals in the south west region of Nigeria.Retrospective review of case records of all surgically managed cases of uterine leiomyoma over a period of 25 years. One hundred and fifty nine women with uterine leiomyoma seen and managed surgically in South-Western Nigeria were the participants.

Results

The common presenting complaints were menstrual irregularities (47.7%), abdominal swelling (39.1%) and infertility (31.9%). The average uterine size at presentation was 15±9.7 weeks. The majority (79.9%) of the women presented with multiple leiomyomata. The commonest anatomical position of the nodules were multiple positions and intramural in 707(60.9%) and 172(14.8%) respectively. Myomectomy was performed in 54.7% of cases. Postoperative complications occurred in 20.9 % of cases with postoperative pyrexia (13.5%), blood loss warranting transfusion (12.8%) and postoperative anaemia (10.4%) been the most common complications.

Conclusion

Uterine fibroid is common in our environment and its removal is commonly associated with post-operative pyrexia, blood loss, and anaemia and wound infection. Midline incision, closure of rectus sheet with chromic catgut and myomectomy were associated with postoperative complications in this review.     

Management of Bleeding Uterine Arteriovenous Malformation with Bilateral Uterine Artery Embolization

Purpose

To evaluate the technical feasibility and clinical outcome of bilateral uterine artery embolization (UAE) as a first-line therapeutic option for bleeding uterine arteriovenous malformation (AVM).

Materials and Methods

Between 2002 and 2012, 19 patients were diagnosed with acquired uterine AVM clinically and through imaging studies. The clinical characteristics, angiographic features, technical success rate of embolization, procedure-related complications, imaging, and clinical follow-up data were assessed. Clinical success was defined as immediate symptomatic resolution with disappearance of vascular abnormality on subsequent imaging studies.

Results

A total of 20 bilateral UAE, with or without embolization of extra-uterine feeders, were performed as the first-line treatment. Technical and clinical success rate was 90.0% (18/20) and 89.5% (17/19), respectively. Embolization was incomplete in two patients who had residual extra-uterine fine feeders to the AVM or a procedure-related complication (ruptured uterine artery); the former showed slow regression of the vascular malformation during the observation period, while the latter underwent a successful second bilateral UAE. Immediate clinical success was achieved in the remaining 17 patients after a single session and no recurrence of bleeding was found. Recovery to normal menstrual cycle was seen in all 17 patients with clinical success within one or two months, two of whom subsequently had uneventful intrauterine pregnancies carried to term.

Conclusion

Bilateral UAE is a safe and effective first-line therapeutic option for the management of bleeding uterine AVMs. However, incomplete embolization due to unembolizable feeders or difficult access into the uterine artery may lead to suboptimal treatment.     

Effectiveness of GPs in accident and emergency departments

Background

Many self-attending patients make inappropriate use of accident and emergency departments.

Aim

To determine whether a new care method consisting of the involvement of a GP during the day with the staff of the accident and emergency department of an academic city hospital and application of the Nederlands Triage Systeem by a practice nurse is more effective than usual care.

Design

Before and after intervention design.

Setting

Accident and emergency department in the VU University Medical Center in Amsterdam.

Method

Participants were patients (n = 1527) attending the accident and emergency department without a referral, on weekdays from 10.00–17.00 hours, from 1 November 2006 to 30 April 2007. The intervention consisted of a new care method that combined the involvement of a GP in the accident and emergency department and allocation of patients by triage to either the GP or the accident and emergency department physician. Main outcome measures were patient satisfaction, number and type of additional examinations, quality of diagnosis, process time, and treatment time.

Results

Patient satisfaction with the treatment increased significantly. Compared to the usual care method, this new care method resulted in a 13% decrease in additional examinations. The percentage of incorrect diagnoses (1 %), as a measure of quality of care, was similar with the two methods. The mean process time decreased from 93 to 69 minutes (P<0.001). The mean treatment time decreased from 60 to 35 minutes (P<0.001).

Conclusion

The new care method resulted in greater patient satisfaction and maintained the quality of care, with fewer additional examinations. It reduced both the process time and the treatment time.     

Urinary schistosomiasis in Zimbabwean school children: predictors of morbidity

Background

The morbid effects of urinary bilharziasis are becoming more evident with the advent of sophisticated diagnostics such as ultrasound. However, such diagnosis of Schistosoma haematobium morbidity is often hampered by lack of funds, proper equipment, or training.

Objective

We performed a cross-sectional investigation of schoolchildren in a highly endemic area of east central Zimbabwe in order to assess the utility of a number of simple clinical indicators to predict Schistosoma haematobium morbidity.

Methods

Prevalence and intensity of S. haematobium infection was determined in 551 schoolchildren, with ultrasound examination of the kidneys and bladder performed on 222. The association of a number of demographic, parasitological, and clinical parameters with clinical outcome was evaluated.

Results

Overall, 60% of the children were infected with S. haematobium. Although lacking specificity, proteinuria and parasite eggs count best predicted bladder pathology. Presence of kidney dilation was associated with fatigue and pain upon urination, but these variables were not very sensitive.

Conclusions

None of the variables assessed were ideal predictors of morbidity. However, the results suggest that a combination of inexpensive, simple indicators may allow for improved targeting of S. haematobium treatment to those with severe morbidity and better monitoring of the progress of control campaigns when more expensive diagnostic methods are not available.     

National Athletic Trainers' Association Position Statement: Acute Management of the Cervical Spine–Injured Athlete

Objective:

To provide certified athletic trainers, team physicians, emergency responders, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in the athlete.

Background:

The relative incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and the timeliness of transfer to a controlled environment for diagnosis and treatment.

Recommendations:

Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport, such as football, hockey, or lacrosse; and considerations in the emergency department.     

Uninfected Para-Anastomotic Aneurysms after Infrarenal Aortic Grafting

Purpose

This single-institution retrospective review examines the management of uninfected para-anastomotic aneurysms of the abdominal aorta (PAAA), developed after infrarenal grafting.

Materials and Methods

From October 1979 to November 2005, 31 PAAA were observed in our Department. Twenty-six uninfected PAAA of degenerative etiology, including 24 false and 2 true aneurysms, were candidates for intervention and retrospectively included in our database for management and outcome evaluation. Six (23%) patients were treated as emergencies. Surgery included tube graft interposition (n = 12), new reconstruction (n = 8), and graft removal with extra-anatomic bypass (n = 3). Endovascular management (n = 3) consisted of free-flow tube endografts.

Results

The mortality rate among the elective and emergency cases was 5% and 66.6%, respectively (p = 0.005). The morbidity rate in elective cases was 57.8%, whereas 75% in emergency cases (p = 0.99). The survival rate during the follow-up was significantly higher for elective cases than for emergency cases.

Conclusion

Uninfected PAAA is a late complication of aortic grafting, tends to evolve silently and is difficult to diagnose. The prevalence is underestimated and increases with time since surgery. The mortality rate is higher among patients treated as an emergency than among patients who undergo elective surgery, therefore, elective treatment and aggressive management in the case of pseudoaneurysm are the keys to obtain a good outcome. Endovascular treatment could reduce mortality. Patients who undergo infrarenal aortic grafting require life-long surveillance after surgery.     

Pattern and outcome of childhood intestinal obstruction at a Tertiary Hospital in Nigeria

Background

Intestinal obstruction is a common cause of pediatric surgical emergency with a high morbidity and mortality in Africa.

Methods

A retrospective review of cases managed from January 1996 to December 2005 at a teaching hospital in Southwestern, Nigeria was done to examine the pattern of causes of intestinal obstruction in children and the management outcome.

Results

One hundred and thirty cases were seen over the study period with an age range of 2 hours to 14 years. Majority (61.24%) were infants, while 18.46% were neonates.Fifty-five cases (42.31%) were due to congenital causes while the rest were of acquired causes. The major causes of intestinal obstruction in the study were intussusception (29.23%), anorectal malformations (22.31%), obstructed inguinoscrotal hernia (16.92%) and Hirschsprung''s disease (13.85%). Surgical site infection and sepsis were the commonest complications observed with an overall complication rate of 60.78%. The mortality rate was 3.08% and most (75%) occurred in neonates.

Conclusion

While mortality as an outcome of management is low, the morbidity was very high in this study.     

Primary care access and its relationship with emergency department utilisation: an observational, cross-sectional, ecological study

Background

Recent health service policies in the UK have focused on improving primary care access in order to reduce the use of costly emergency department services, even though the relationship between the two is based on weak or little evidence. Research is required to establish whether improving primary care access can influence emergency department attendance.

Aim

To ascertain whether a relationship exists between the degree of access to GP practices and avoidable emergency department attendances in an inner-London primary care trust (PCT).

Design and setting

Observational, cross-sectional ecological study in 68 general practices in Brent Primary Care Trust, north London, UK.

Method

GP practices were used as the unit of analysis and avoidable emergency department attendance as the dependent variable. Routinely collected data from GP practices, Hospital Episode Statistics, and census data for the period covering 2007–2009 were used across three broad domains: GP access characteristics, population characteristics, and health status aggregated to the level of the GP practice. Multiple linear regression was used to ascertain which variables account for the variation in emergency department attendance experienced by patients registered to each GP practice.

Results

None of the GP access variables accounted for the variation in emergency department attendance. The only variable that explained this variance was the Index of Multiple Deprivation (IMD). For every unit increase in IMD score of the GP practice, there would be an increase of 6.13 (95% CI = 4.56, 7.70) per 1000 patients per year in emergency department attendances. This accounted for 47.9% of the variance in emergency department attendances in Brent.

Conclusion

Avoidable emergency department attendance appears to be mostly driven by underlying deprivation rather than by the degree of access to primary care.     

Predictive factors for pelvic magnetic resonance in response to arterial embolization of a uterine leiomyoma

OBJECTIVE:

Minimally invasive methods are used as alternatives to treat leiomyomas and include uterine artery embolization, which has emerged as a safe, effective method. This study aims to evaluate the magnetic resonance imaging predictors for a reduction in leiomyoma volume in patients undergoing uterine artery embolization.

METHODS:

This prospective longitudinal study was performed at a university hospital. We followed 50 symptomatic premenopausal women with uterine leiomyomas who underwent uterine artery embolization. We examined 179 leiomyomas among these patients. Magnetic resonance imaging was performed one month before and six months after uterine artery embolization. Two radiologists who specialized in abdominal imaging independently interpreted the images. Main Outcome Measures: The magnetic resonance imaging parameters were the uterus and leiomyomas volumes, their localizations, contrast perfusion pattern and node-to-muscle ratio.

RESULTS:

Six months after treatment, the average uterine volume reduction was 38.91%, and the leiomyomas were reduced by 55.23%. When the leiomyomas were submucosal and/or had a higher node-to-muscle ratio in the T2 images, the volume reduction was even greater (greater than 50%). Other parameters showed no association.

CONCLUSIONS:

We conclude that symptomatic uterine leiomyomas in patients undergoing uterine artery embolization exhibit volume reductions greater than 50% by magnetic resonance imaging when the leiomyomas are submucosal and/or had a high node-to-muscle ratio in the T2 images.     

Ultrasound and Joint Mobilizations for Achieving Normal Wrist Range of Motion After Injury or Surgery: A Case Series

Context:

Regaining full, active range of motion (AROM) after trauma to the wrist is difficult.

Objective:

To report the cases of 6 patients who lacked full range of motion (ROM) in the wrist due to trauma. The treatment regimen was thermal 3-MHz ultrasound and joint mobilizations.

Design:

Case series.

Setting:

University therapeutic modalities laboratory.

Patients or Other Participants:

Six patients (2 women, 4 men) from the university population lacked a mean AROM of 21.7° of flexion and 26.8° of extension approximately 2.1 years after trauma or surgery.

Main Outcome Measure(s):

I assessed changes in flexion and extension AROM before and after each treatment. Treatment consisted of 6 minutes of 3-MHz continuous ultrasound at an average intensity of 1.4 W/cm² on the dorsal and volar aspects of the wrist, immediately followed by approximately 10 minutes of joint mobilizations. After posttreatment ROM was recorded, ice was applied to the area for about 20 minutes. Once the patient achieved full AROM or did not improve on 2 consecutive visits, he or she was discharged from the study.

Results:

By the sixth treatment, 5 participants achieved normal flexion AROM, and 3 exceeded the norm. All 6 achieved normal extension AROM, and 4 exceeded the norm. All returned to normal activities and normal use of their hands. One month later, they had, on average, maintained 93% of their final measurements.

Conclusions:

A combination of thermal ultrasound and joint mobilizations was effective in restoring AROM to wrists lacking ROM after injury or surgery.     

Two Modes of Weight Training Programs and Patellar Stabilization

Context:

Underconditioned patellar stabilizing muscles could be a predisposing factor for patellar instability.

Objective:

To examine the effect of 2 modes of weight training on the size of the vastus medialis obliquus (VMO), the resting position and passive mobility of the patella, and the strength of the knee extensor muscles.

Design:

Prospective intervention, repeated measures in 3 groups.

Setting:

Orthopaedic and sports sciences research laboratory.

Patients or Other Participants:

48 healthy adults free from back and lower extremity injuries.

Intervention(s):

Participants were randomly assigned to muscle hypertrophy training, muscle strength training, or the control group. Those in the training groups pursued training 3 times per week for 8 weeks.

Main Outcome Measure(s):

Magnetic resonance imaging and ultrasound cross-sectional area of the VMO, patellar tilt angle on magnetic resonance imaging, instrumented passive patellar mobility, and isometric knee extension torque of the dominant leg.

Results:

Participants in both training groups had comparable gains in VMO size, passive patellar stability, and knee extension force, all of which were greater than for the control group (P < .05).

Conclusions:

Both short-term muscle hypertrophy and strength training programs can reinforce the patellar stabilizers in previously untrained volunteers.     

Cesium Implant for Tongue Carcinoma with a Thickness of 1.5 cm or More: Cases Successfully Treated with a Modified Manchester System

Purpose

Deciding on treatment carcinoma of the tongue when the tumor has a thickness of 1.5 cm or more is difficult. Surgery often requires wide resection and re-construction, leading to considerable functional impairment. A cesium implant is an attractive option, but according to the Manchester System, a two plane implant is needed.

Materials and Methods

According to the textbook, a tumor is sandwiched between the needles, which are implanted at the edge of the tumor. This may cause an unnecessarily high dose to the outer surface of the tongue, which sometimes leads to a persistent ulcer. To avoid this complication, we invented a modified implantation method, and applied the method to five consecutive patients.

Results

With a minimum follow-up of 2 years, all primary tumors in 5 consecutive patients have been controlled. No complications occurred in soft tissue of the tongue or in the mandible.

Conclusion

Our modified Manchester System was feasible and effective for tumors that has a thickness of 1.5 cm or more.     

Maternal postpartum complications according to delivery mode in twin pregnancies

OBJECTIVE:

We aimed to examine maternal postpartum complications of twin deliveries according to mode of delivery and investigate the associated risk factors.

METHODS:

This was a retrospective cohort review of twin pregnancies with delivery after 26 weeks at a tertiary teaching hospital (1993-2008). The rates of maternal postpartum complications were compared among vaginal, elective cesarean and emergency cesarean deliveries. Significant predictors of complications were investigated with stepwise regression analysis and relative risks were calculated.

RESULTS:

A total of 90 complications were observed in 56/817 (6.9%) deliveries: 7/131 (5.3%) vaginal, 10/251 (4.0%) elective cesarean and 39/435 (9.0%) emergency cesarean deliveries. Significant predictors included high-risk pregnancy, gestational age at birth and delivery mode. The occurrence of complications was significantly increased in emergency compared to elective cesarean deliveries (RR = 2.34).

CONCLUSIONS:

Maternal postpartum complications in twin pregnancies are higher in emergency compared to elective cesarean deliveries and are also related to preexisting complications and earlier gestational age at delivery.     

Temperature Increases in the Human Achilles Tendon During Ultrasound Treatments With Commercial Ultrasound Gel and Full-Thickness and Half-Thickness Gel Pads

Context:

Although originally manufactured for use in diagnostic imaging of internal structures, 2-cm-thick gel pads are also used as conducting media for therapeutic ultrasound over areas with bony prominences. Research on the ability of these pads to conduct enough energy to adequately heat tissues has provided mixed results. However, this research has mainly been performed on the triceps surae muscle, an area over which gel pads are not typically used. We wondered how much heating might be produced if a thinner pad was used over a tendon.

Objective:

To compare temperature rises in the human Achilles tendon during ultrasound treatments using ultrasound gel, a 2-cm-thick pad, and a 1-cm-thick pad.

Design:

Cross-sectional study.

Setting:

University therapeutic modality laboratory.

Patients or Other Participants:

Forty-eight healthy volunteers (24 women, 24 men).

Intervention(s):

We inserted a rigid thermocouple 1 cm deep into the Achilles tendon. Ultrasound was delivered at the following settings: 3 MHz, continuous, 1 W/cm², 10 minutes.

Main Outcome Measure(s):

Temperature was recorded every 30 seconds for 10 minutes.

Results:

Temperature increased the most in the ultrasound gel group (increase  =  13.3°C, peak  =  42°C). The 1-cm-thick pad resulted in higher tendon temperature (increase  =  9.3°C, peak  =  37.8°C) than the 2-cm-thick pad (increase  =  6.5°C, peak  =  4.8°C). The 1-cm pad produced approximately 30% more heating than the 2-cm pad (SE  =  0.72, P < .03).

Conclusions:

The thinner pad transmitted ultrasound more efficiently than the thicker pad. Thus, a gel pad of less than 1-cm thickness might be useful for superficial areas, such as the hands and ankles.