Lower genital tract disease in children and adolescents--a review

Conditions affecting the lower genital tract of female children and adolescents are often significantly different than those seen in the adult. The purpose of this review is to provide an overview of vulvar, vaginal, and cervical conditions that may be encountered only rarely by the more generalized practitioner.     

绝经后泌尿道疾患和处理对策

女性在绝经后会发生一系列的泌尿生殖道的改变。在肾脏的病理改变为肾血流量减少;肾小球滤过率降低;肾小管排泄下降;肾小管再吸收减少等肾功能降低表现。而在膀胱可发生如下改变:膀胱外结缔组织减少;膀胱颈周围弹力纤维减少;尿道黏膜及黏膜下组织厚度变薄;膀胱容量降低,逼尿肌不稳定性增强。这些泌尿道的病理改变使部分女性在绝经后发生疾病,影响绝经后妇女的生活质量,现把常见绝经后泌尿道症状与疾患分述如下。1常见绝经后泌尿道症状表现(1)尿急:是指一种突发、强烈的排尿欲望,且很难被主观抑制而延迟排尿。(2)尿频:为一种主诉,指患者自觉…     

Biliary Tract Disease in Pregnancy

The timely diagnosis and treatment of biliary tract conditions during pregnancy are challenging. Familiarity with the anatomic and physiologic changes present in normal pregnancy is essential, as is the knowledge of relative risk of complications by trimester. Physicians should be aware that virtually all complications that occur in the management of these conditions are caused by delay in the detection of the disease process. Recent advances in minimally invasive therapy including laparoscopic surgery and therapeutic gastro-intestinal endoscopy have changed the traditional approach to biliary tract disease in pregnancy. We present a case report of a patient with acute gallstone pancreatitis during pregnancy managed endoscopically without the use of fluoroscopy.     

Periodontal disease and upper genital tract inflammation in early spontaneous preterm birth

OBJECTIVE: To estimate the relationship between maternal periodontal disease and both early spontaneous preterm birth and selected markers of upper genital tract inflammation. METHODS: In this case-control study, periodontal assessment was performed in 59 women who experienced an early spontaneous preterm birth at less than 32 weeks of gestation, in a control population of 36 women who experienced an early indicated preterm birth at less than 32 weeks of gestation, and in 44 women with an uncomplicated birth at term (>or = 37 weeks). Periodontal disease was defined by the degree of attachment loss. Cultures of the placenta and umbilical cord blood, cord interleukin-6 levels, and histopathologic examination of the placenta were performed for all women. RESULTS: Severe periodontal disease was more common in the spontaneous preterm birth group (49%) than in the indicated preterm (25%, P =.02) and term control groups (30%, P =.045). Multivariable analyses, controlling for possible confounders, supported the association between severe periodontal disease and spontaneous preterm birth (odds ratio 3.4, 95% confidence interval 1.5-7.7). Neither histologic chorioamnionitis, a positive placental culture, nor an elevated cord plasma interleukin-6 level was significantly associated with periodontal disease (80% power to detect a 50% difference in rate of histological chorioamnionitis, alpha = 0.05). CONCLUSION: Women with early spontaneous preterm birth were more likely to have severe periodontal disease than women with indicated preterm birth or term birth. Periodontal disease was not associated with selected markers of upper genital tract inflammation. LEVEL OF EVIDENCE: II-2     

Parasitic disease of the female genital tract: histopathological aspects

In temperate countries, Trichomonas and Candida are the most frequently found agents in parasitic disease of the female genital tract but usually a surgical step is not required. On the contrary, erratic infectation with Helminths (Enterobius vermicularis, Ascaris, Tapeworm, Echinococcus granulosus) can cause genital or peritoneal lesions and an operation becomes then necessary. Diagnosis is made only a posteriori by histological examination. In countries with endemic Schistosoma infestation, localizations of S. haematobiumn in the vaginal wall, cervix uteri, Fallopian tubes and ovary, and sometimes even pelvic peritoneum predominate by far in the pathology of parasitic disease of the genital tract. Usually latent, such infestations can sometimes cause severe and pseudotumoral lesions, the cause of which, here again, if often detected only by histopathological investigation.     

Adjunctive choledochoduodenostomy to choledocholithotomy in the treatment of calculous biliary tract disease.

Between 1986 and 1991, 16 selected patients with calculous biliary tract disease (CBTD) underwent side-to-side choledochoduodenostomy (CDS) as an adjunct to either primary (10 patients) or secondary (six patients) choledocholithotomy. Patients selected for adjunctive CDS were those with common bile duct dilatation > or = 1.5 cm in size. All operations were elective procedures. The stoma of the CDS was about 3.0 cm in size, measured directly. There were no operative deaths. There were no early complications related to the CDS procedure itself, except for two (12.5%) wound infections. CDS significantly eliminates bile stasis which is indicated by a fall in both the serum levels of alkaline phosphatase (from 228 +/- 118 to 72 +/- 22 IU/L, p < 0.01) and total bilirubin (from 4.7 +/- 4.7 to 0.9 +/- 0.2 mg/dL, p < 0.01) postoperatively. Late complications (ascending cholangitis or sump syndrome) of CDS or recurrent symptoms of CBTD were not encountered during the average follow-up period of 21 +/- 18 months. From our clinical results, we suggest that adjunctive CDS to choledocholithotomy is a safe and effective procedure in the treatment of selected patients with CBTD.     

Biliary cysts in children--long-term follow-up in Taiwan.

BACKGROUND: This study analyzed the clinical presentation, postoperative morbidity and mortality and incidence of associated extrahepatic biliary atresia in children with biliary cysts in Taiwan. METHODS: We retrospectively reviewed the records of 158 pediatric patients with biliary cysts seen between June 1981 and July 2004, with follow-up ranging from 12 months to 22 years (mean, 11.2 +/- 6.1 years). Patients were divided into three groups: biliary atresia-associated biliary cyst (BABC, 21 patients), non-biliary atresia-associated choledochal cyst (NBACC) in infancy (37 patients), and late NBACC (> 1 year of age, 100 patients). RESULTS: BABC accounted for 36.2% of the infantile biliary cysts in this study. Extrahepatic cysts in late NBACC had a greater mean diameter than those in infantile NBACC and BABC (21.5 mm vs. 16.0 mm vs. 7.9 mm, p < 0.001). Cholangitis was the most serious complication within 3 months postoperatively in all three groups, resulting in four deaths (two in the infantile NBACC group and one each in the other two groups). Liver cirrhosis developed during long-term follow-up in nine of the 21 patients with BABC, four of whom died. Three of these nine patients underwent liver transplantation and remained well during follow-up. Chronic complications in NBACC occurred mainly in late IVa cases, with persistent intrahepatic dilatation developing in 12 of 35 patients and intrahepatic stones in five. Elevation of serum alanine aminotransferase (ALT) was found preoperatively in 85% of late NBACC and 35% of infantile NBACC cases. Postoperative normalization of ALT occurred after a mean of 152 +/- 23 days and 158 +/- 67 days in late NBACC and infantile NBACC, respectively. Higher ALT levels before operation were associated with a longer period until normalization. CONCLUSION: The possibility of BABC must be included in the differential diagnosis when a small extrahepatic cyst (< 8 mm in diameter) with prolonged jaundice is found in infancy. Postoperative follow-up is essential for patients with NBACC due to their frequently prolonged elevation of serum ALT and possibility of residual intrahepatic dilatation. Cholangitis was the major cause of death within 3 months postoperatively in this study.     

Calculous disease of the biliary tract in infants after neonatal extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) can be lifesaving support for neonates with fulminant respiratory failure. In the 121 patients that we have placed on ECMO since 1983, bleeding, infection, and intracranial hemorrhage have constituted most of the major complications. We have also encountered two cases of biliary calculi in post-ECMO infants. The hemolysis, total parenteral nutrition, diuretics, and prolonged fasting associated with ECMO may predispose neonates to early calculous disease of the biliary tract and may require surgical intervention. Evaluation of abdominal pain or jaundice in infants and children who have been supported with ECMO should include examination of the biliary tree. Cholecystectomy should be seriously considered for infants with cholelithiasis.     

Biliary lipid metabolism in the pregnant baboon.

The serum cholesterol value, bile acid pool size and kinetics as well as lipid composition of gallbladder bile have been studied in seven baboons during nine pregnancies. During pregnancy, the per cent decrease in the average serum cholesterol value ranged from 25.6 to 74.4 per cent, mean 54.5 +/- 14.3 per cent, compared with that of antepartum averages. In seven of the nine pregnancies, chenodeoxycholic acid pool size decreased in the range of 40.1 to 86.6 per cent. In two pregnancies, the pool size of this bile acid was essentially unchanged. Total bile acid pool size also decreased from a mean of 990 +/- 260 milligrams antepartum to 520 +/- 200 milligrams in the third trimester, p less than 0.01. With regard to the cholesterol, phospholipid and bile salt content of gallbladder bile, cholesterol value decreased from an antepartum mean of 19.1 +/- 3.9 to 14.1 +/- 4.5 micromoles per milliliter in the third trimester. As a consequence, the lithogenic index of gallbladder bile decreased during pregnancy. The changes in chenodeoxycholic and total bile acid pool size are qualitatively similar to those reported by other investigators following the administration of estrogens to both baboons and other animal species. In the pregnant baboon, the decrease in pool size and in synthesis rate of bile acids is accompanied by a decrease in the cholesterol content of gallbladder bile. These changes in the lipid content of gallbladder bile are reflected in a decrease in the mean lithogenic index. These data suggest that the baboon may be an inappropriate model for studies of the relationship of pregnancy to cholesterol cholelithiasis in humans. In the baboon, both serum and biliary cholesterol values decrease during pregnancy. In humans, serum cholesterol levels increase during pregnancy. If the content of biliary cholesterol is a reflection of the serum concentration of this lipid, as has been suggested in recent studies, human bile may be more lithogenic during pregnancy. Additional studies are necessary to define the role of gallbladder contractility and bile stasis to gallstone formation during pregnancy.     

Maternal and child health care in Thailand

Primary health care, especially in the area of maternal and child health care, in Thailand is mostly provided by non-professional village health volunteers. There are only about 7000 doctors in Thailand, the population of which is 50 million. While 80% of the population are engaged in agriculture in rural areas, most of the doctors reside and practice in Bangkok, the capital. Under Ministry of Public Health in the capital are 6 provincial health offices which include maternal and child health care centers. These maternal health care centers have about 100 beds, many midwives and some doctors. The fee for a normal child birth including three-day hospital stay is about $12 to $20. They also offer a 2-year training program in midwifery. Underneath the Provincial Health Office are District Health Offices followed by town health centers at the sub-District level and Village Health Volunteers (VHV) plus Village Health Communicators (VHC) at the village level. For villagers, closest available medical professionals are 1 or 2 midwives working in the town health centers. Their day to day primary health care heavily depends on VHV and VHC. VHV consist of men and women over 30 years of age who are interested in health care and who received 15-day intensive training. Each VHV has several VHC as assistance. for the past 20 years the Thai government has taken the policy of "2 children per family" via contraception since abortion is prohibited by law in Thailand. VHV plays an important role in educating villagers in the area of contraception. Lately the population increase rate has become too low.     

Postpartum sterilization by operating-room nurses in Thailand

A training project to assess the performance of experienced operating room nurses as operators in postpartum sterilization was conducted in 1977-1978. The results for over 1000 nurse-operated clients and a comparison group of approximately 300 physician-sterilized clients show that nurses achieved comparable success with physicians in postpartum sterilization, as judged by clinical and attitudinal follow-up. No serious complications were recorded in either group. Minor infections in both groups were treated routinely. A stitch abscess for one nurse-operated client resulted in hospitalization; the client was released after 3 days. The clients in both groups returned to routine chores at home rapidly, and client satisfaction with the procedure was virtually unanimous in each group. This study lends support to the use of nurses in performing contraceptive surgery. The need for increased service coverage in this area is of high priority, and nurses provide a readily available and easily trained cadre of support staff.