46XY girls: the importance of careful newborn examination

Study ObjectiveTo understand the timing and factors affecting diagnosis of phenotypically female 46XY children.Design, Setting, and ParticipantsWe studied all phenotypically female 46XY children who attended our multidisciplinary disorders of sexual differentiation (DSD) clinic in Nottingham England in a 3-year period since its inception. Case notes from a prospectively maintained database were reviewed and data were analyzed on the age at presentation, family history, findings on genital examination, and underlying endocrine abnormality.ResultsEleven children were studied, all of whom were being raised as girls. The median age of presentation was 18 months (range birth-15 years). Although the newborn examination detected the possibility of DSD in only 3 cases; 10 of 11 children had at least one significant abnormality in their external genitalia at presentation.ConclusionCareful neonatal genital examination can identify children with DSD. However, not all children with these conditions are identified early. Early diagnosis, when possible, is important, as it has the potential to make the management of this difficult condition more straightforward.     

Importance of a specialized pathologist for the examination of frozen sections of adnexal masses

The aim of the present study was to examine the impact of a specialized pathologist on the accuracy of frozen section analysis for adnexal masses. We included women who underwent frozen section diagnosis for adnexal mass surgery. A specialized and a general pathologist read the sections. We calculated sensitivity, specificity, positive and negative predictive values, and accuracy for the whole series, as well as for the specialized and general pathologist groups. We included 325 patients; in 103 patients (31.7%), frozen section diagnosis was performed by the specialized and in 222 (68.3%), by the general pathologist. There was a significant difference in terms of correspondence between the specialized and the general pathologist groups (P= 0.024). We registered four overdiagnoses (both performed by the general pathologist [1.8% vs 0%]) and 56 underdiagnoses of which 14 (13.6%) were made by the specialized pathologist and 46 (20.7%) by the general pathologist. In 14 cases (4.3%), diagnosis could not be made on frozen section and was postponed to final histology for definitive diagnosis (1/103 [0.9%] for the specialized pathologist and 13/222 [5.8%] for the general pathologist). Our data confirm previous reports on the accuracy of frozen section analysis of adnexal masses and show a significant positive impact of the specialized pathologist as opposed to the general pathologist.     

In vivo ultrasonographic exposimetry: human tissue-specific attenuation coefficients in the gynecologic examination

OBJECTIVE: The purpose of the current study was to determine in vivo, tissue-specific ultrasonic attenuation coefficients for each of the tissue layers comprising the anterior abdominal wall, uterus, and vagina with use of a quantitative multilayer tissue model. We wanted to validate the "homogeneous" tissue model-based Food and Drug Administration derating factor of 0.3 dB/cm-MHz applied to obstetric-use ultrasonography systems. STUDY DESIGN: With use of a 3. 0-MHz mechanical sector scanner and our previously tested exposimetry equipment, we obtained a set of at least 5 separate acoustic pressure waveforms from each test subject by placing a calibrated 7-element linear-array hydrophone in the anterior vaginal fornix while she was undergoing transabdominal ultrasonography. Corresponding sets of reference in vitro acoustic pressure waveforms were also recorded for each test subject in a 37 degrees C water bath. All linear measurements of individual layer thicknesses and total distances were made on-line with use of electronic calipers. A set of multiple and independent insertion loss values, denoted ILn, was calculated for path n between the abdominal surface and the hydrophone from n sonograms for each test subject. Each tissue layer type was identified and its thickness along each path n was measured. The thickness of tissue type m along path n was denoted by dnm. The only unknown quantities left were the attenuation coefficients Am of each of the m tissue layers for that test subject. The overestimated set of equations dnm Am = ILn was solved for Am with use of a nonnegative least-squares solution technique. RESULTS: With use of data from 162 independent insertion loss estimate paths, the overall tissue-specific attenuation coefficients for each of the tissue layer types, expressed as mean value +/- SD, were 2.3 +/- 1.5 dB/cm-MHz for the skin and subcutaneous layer, 3.1 +/- 2.5 dB/cm-MHz for skeletal muscle, 0.6 +/- 0.5 dB/cm-MHz for myometrium, and 3.6 +/- 2.7 dB/cm-MHz for the vaginal wall. The overall insertion loss assuming the "homogeneous" tissue model was 0.7 +/- 0.3 dB/cm-MHz. CONCLUSIONS: We have determined the specific ultrasonic attenuation coefficients for each of the tissue layers comprising the anterior abdominal wall, uterus, and vagina and validated the Food and Drug Administration derating factor of 0.3 dB/cm-MHz applied to obstetric use ultrasonography systems. Of all the models proposed, the "homogeneous" tissue model appears to be the best model for determining ultrasonic exposure risk during reproductive ultrasonographic examinations.     

The role of the pathologist in the surgical treatment of hyperparathyroidism

Appropriately extensive surgical treatment of hyperparathyroidism depends upon accurate assessment of the extent of disease. We have believed that such assessement is the responsibility of the surgeon because at random biopsy with light microscopy the pathologist may not be able to differentiate adenoma from hyperplasia or even normal from abnormal glands. To test this hypothesis, three pathologists reviewed 50 unlabelled slides of parathyroid tissue and attempted to correlate them with clinical diagnoses which were based upon widely accepted criteria. They were asked to identify each slide as adenoma or hyperplasia, or both, or normal using whatever criteria they wished. A specific diagnosis of adenoma was correct in 35 and 83 per cent of interpretations and of hyperplasia in 38 and 60 per cent of interpretations. The less specific diagnosis of adenoma or hyperplasia (that is, abnormal tissue) was correct in 78 to 100 per cent. A diagnosis of normal was correct in 71 to 78 per cent. Adenoma was most likely confused with hyperplasia; hyperplasia was equally mistaken for adenoma or normal. We conclude that with random, subtotal specimens taken at biopsy (simulating intraoperative conditions) differentiation of adenoma from hyperplasia of the parathyroid gland is poor. Differentiation of normal from abnormal parathyroid tissue also is unreliable. Because the consequences of misdiagnosis are severe, pathologists should not be asked to make specific diagnoses intraoperatively but only to distinguish the parathyroid tissue from the nonparathyroid tissue.     

Methadone and the pregnant user: a matter for careful clinical consideration

The practice of placing all pregnant heroin users on methadone as the treatment of choice needs to be questioned. While it may be suitable for those who stabilise their illicit heroin use at or shortly after conception, its suitability for those who show little movement away from regular heroin use and its associated lifestyle is more circumspect. Neonates of women who continue heroin use throughout pregnancy are likely to be below birthweight and/or premature. As a consequence, they are in a less than optimal condition to cope with the additional assault caused by prescribed methadone such as neonatal withdrawal. This may help explain why the relative risk of neonatal mortality in women who continue illicit heroin use during pregnancy and are prescribed methadone, is greater than for those who continue to use heroin but are not prescribed methadone. Clinicians must take the time of maternal presentation and the likelihood of continued maternal heroin use into consideration when determining who is suitable for methadone and whether a reduced level of methadone will suffice. A number of different clinical scenarios are identified and possible management strategies discussed. The need to develop innovative services appropriate for pregnant women who continue regular heroin use, and for well-designed studies that define best practice for the management of these women is evident.     

Correlation between visual examination of the cervix and digital examination

Objective.?To determine the correlation between visual assessment of the cervix and digital examination.

Methods.?Prospective study of patients presenting to Labor and Delivery. Exclusion criteria were preterm premature ruptured membranes (PPROM) and placenta previa. Visual and digital assessments of cervical dilation, effacement, position, and station of fetal presenting part were made. Correlation between visual and digital examinations was measured using Spearman rank correlation coefficient (COR). A p-value <?0.05 was considered significant.

Results.?The study involved a total of 107 patients at a mean gestational age of 32.3 weeks (range 17–41). Seven patients had ruptured membranes, and 46 were nulliparous. Visual assessment correlated with digital examination for all parameters measured with Spearman rank correlation coefficients between 0.618 and 0.686 (all significant at p?<?0.001). Correlations between visual and digital assessment of cervical dilation, effacement, station, and position were not as strong (0.291–0.699), but remained significant (p?<?0.02) in a subgroup of 50 preterm patients <?34 weeks gestation.

Conclusion.?Visual assessment correlates with digital examination of the cervix. This correlation remained significant in a subset of preterm patients with intact membranes.     

Laparoscopy and ultrasound examination in women with acute pelvic pain

The results of preoperative pelvic examination and eventual ultrasound examination were correlated with the laparoscopic findings in 316 women with acute pelvic pain. The predictive values of normal and abnormal findings at pelvic examination were 46.9 and 82.1%, respectively. 42.1% of the women had ultrasound examination performed. This investigation showed to be helpful especially in patients with normal findings at pelvic examination. If ultrasonic findings were abnormal the results at laparoscopy were also abnormal in 90%. On the contrary, normal findings at ultrasound examination did not exclude abnormal pelvic findings. The predictive value of normal results at ultrasound examination was 50.0%. This discrepancy between ultrasonic and pelvic findings can be explained by the size of the pelvic masses. Ultrasound examination is a valuable tool in the evaluation of patients with acute pelvic pain, but it cannot replace laparoscopy.     

Correlation between visual examination of the cervix and digital examination.

OBJECTIVE: To determine the correlation between visual assessment of the cervix and digital examination. METHODS: Prospective study of patients presenting to Labor and Delivery. Exclusion criteria were preterm premature ruptured membranes (PPROM) and placenta previa. Visual and digital assessments of cervical dilation, effacement, position, and station of fetal presenting part were made. Correlation between visual and digital examinations was measured using Spearman rank correlation coefficient (COR). A p-value<0.05 was considered significant. RESULTS: The study involved a total of 107 patients at a mean gestational age of 32.3 weeks (range 17-41). Seven patients had ruptured membranes, and 46 were nulliparous. Visual assessment correlated with digital examination for all parameters measured with Spearman rank correlation coefficients between 0.618 and 0.686 (all significant at p<0.001). Correlations between visual and digital assessment of cervical dilation, effacement, station, and position were not as strong (0.291-0.699), but remained significant (p<0.02) in a subgroup of 50 preterm patients<34 weeks gestation. CONCLUSION: Visual assessment correlates with digital examination of the cervix. This correlation remained significant in a subset of preterm patients with intact membranes.