Postoperative Outcomes after Surgery for Deep Endometriosis of the Sacral Plexus and Sciatic Nerve: A 52-patient Consecutive Series

Study ObjectiveTo assess 1-year postoperative outcomes of surgery for deep endometriosis involving the sacral roots and sciatic nerve.DesignRetrospective case series.SettingThree referral centers.PatientsFifty-two women.InterventionsSurgery for deep endometriosis involving the sacral roots and sciatic nerve.Measurements and Main ResultsDeep endometriosis involved the sacral roots in 49 women (94.2%) and the sciatic nerve in 3 cases (5.8%). Sciatic pain (buttock or leg) was recorded in 43 women (82.7%), pudendal neuralgia in 11 women (21.2%), and leg motor weakness in 14 cases (27%). The surgical procedures carried out on the pelvic nerves included complete release and decompression (92.3%), excision of the epineurium by shaving (5.8%), and intraneural excision (1.9%). Additional major surgical procedures involved the digestive tract in 82.7% of the cases and the urinary tract in 46.2%. Rectovaginal fistula occurred in 13.5% of the cases. Self-catheterization was required in 14 cases (27%) at 3 weeks after surgery and in 3 women (5.8%) 12 months later. One-year follow-up showed significant improvement in quality of life measured using the Short-Form 36 questionnaire and standardized gastrointestinal scores. De novo hypoesthesia, hyperesthesia, or allodynia were recorded in 9 women (17.2%). The cumulative pregnancy rate was 77.2%% after natural conception in 47%.ConclusionLaparoscopic management of deep endometriosis involving the sacral roots and sciatic nerve improves patients’ symptoms and overall quality of life. Although pain reduction may be rapid after surgery, other sensory or motor complaints, including bladder dysfunction, may be recorded over months or years.     

Newborn survival: a multi-country analysis of a decade of change

Neonatal deaths account for 40% of global under-five mortality and are ever more important if we are to achieve the Millennium Development Goal 4 (MDG 4) on child survival. We applied a results framework to evaluate global and national changes for neonatal mortality rates (NMR), healthy behaviours, intervention coverage, health system change, and inputs including funding, while considering contextual changes. The average annual rate of reduction of NMR globally accelerated between 2000 and 2010 (2.1% per year) compared with the 1990s, but was slower than the reduction in mortality of children aged 1-59 months (2.9% per year) and maternal mortality (4.2% per year). Regional variation of NMR change ranged from 3.0% per year in developed countries to 1.5% per year in sub-Saharan Africa. Some countries have made remarkable progress despite major challenges. Our statistical analysis identifies inter-country predictors of NMR reduction including high baseline NMR, and changes in income or fertility. Changes in intervention or package coverage did not appear to be important predictors in any region, but coverage data are lacking for several neonatal-specific interventions. Mortality due to neonatal infection deaths, notably tetanus, decreased, and deaths from complications of preterm birth are increasingly important. Official development assistance for maternal, newborn and child health doubled from 2003 to 2008, yet by 2008 only 6% of this aid mentioned newborns, and a mere 0.1% (US$4.56m) exclusively targeted newborn care. The amount of newborn survival data and the evidence based increased, as did recognition in donor funding. Over this decade, NMR reduction seems more related to change in context, such as socio-economic factors, than to increasing intervention coverage. High impact cost-effective interventions hold great potential to save newborn lives especially in the highest burden countries. Accelerating progress requires data-driven investments and addressing context-specific implementation realities.     

Pharmacokinetics of Cefuroxime in Porcine Cortical and Cancellous Bone Determined by Microdialysis

Traditionally, the pharmacokinetics of antimicrobials in bone have been investigated using bone biopsy specimens, but this approach suffers from considerable methodological limitations. Consequently, new methods are needed. The objectives of this study were to assess the feasibility of microdialysis (MD) for measuring cefuroxime in bone and to obtain pharmacokinetic profiles for the same drug in porcine cortical and cancellous bone. The measurements were conducted in bone wax sealed and unsealed drill holes in cortical bone and in drill holes in cancellous bone and in subcutaneous tissue. As a reference, the free and total plasma concentrations were also measured. The animals received a bolus of 1,500 mg cefuroxime over 30 min. No significant differences were found between the key pharmacokinetic parameters for sealed and unsealed drill holes in cortical bone. The mean ± standard error of the mean area under the concentration-time curve (AUC) values from 0 to 5 h were 6,013 ± 1,339, 3,222 ± 1086, 2,232 ± 635, and 952 ± 290 min · μg/ml for free plasma, subcutaneous tissue, cancellous bone, and cortical bone, respectively (P < 0.01, analysis of variance). The AUC for cortical bone was also significantly different from that for cancellous bone (P = 0.04). This heterogeneous tissue distribution was also reflected in other key pharmacokinetic parameters. This study validates MD as a suitable method for measuring cefuroxime in bone. Cefuroxime penetration was impaired for all tissues, and bone may not be considered one distinct compartment.     

Disseminated intravascular coagulation complicating resection of a malignant meningioma

A 70-year-old woman developed disseminated intravascular coagulation (DIC) during a craniotomy for a parasagittal anaplastic/malignant meningioma. This was successfully treated with rapid resection of the tumour and haematological replacement, but a poor neurological outcome resulted. The tumour was demonstrated to express tissue factor, an important causative factor in other tumour associated DIC and previously shown to be expressed by malignant meningiomas. A link between the two is suggested.     

In vivo distribution of bismuth in the mouse brain: influence of long-term survival and intracranial placement on the uptake and transport of bismuth in neuronal tissue

Bismuth is used for a multitude of industrial purposes and has partly replaced toxic heavy metals such as lead and mercury in e.g. lubricants and shotgun pellets. In medicine, bismuth-compounds have long been used to remedy gastrointestinal disorders; lately in combination with antibiotics to treat Helicobacter pylori associated peptic ulcers. An epidemic episode of bismuth-induced encephalopathy in France in the 1970s revealed the neurotoxic potential of bismuth. This incidence, involving almost 1000 patients, remains unexplained and the contribution of other factors besides bismuth has been postulated. Recently an autometallographic technique made it possible to detect bismuth in morphologically intact tissue. In the present study, autometallographicly detectable bismuth was seen throughout the brain following intraperitoneal and intracranial exposure. The neuronal staining pattern seems highly organized with some areas heavily stained and others with low or no staining. Long-term (8 months) intraperitoneal exposure led to higher bismuth uptake than short-term (2 weeks) exposure. Following both intraperitoneal and intracranial exposure, high amounts of bismuth were found in the reticular and hypothalamic nuclei, in the oculomotor and hypoglossal nuclei and in Purkinje cells. Within the central nervous system (CNS) retrograde axonal transport was seen after intracranial bismuth exposure. Axonal transport seems to influence the distribution of bismuth as the highest uptake of bismuth after intraperitoneal exposure was seen in the facial and the trigeminal motor nuclei, i.e. neurones with processes outside the blood-brain barrier, whereas these nuclei contained no bismuth following ic exposure. Ultrastructurally, accumulation of bismuth was seen in lysosomes.     

Alkaloids from Boophane disticha with affinity to the serotonin transporter in rat brain

Bulbs and leaves of Boophane disticha are used in South African traditional medicine in the treatment of anxiety. Crude extracts of the leaves have shown affinity to the SSRI site on the serotonin transporter in a radioligand binding assay. In this study, two compounds, buphanadrine and buphanamine, were isolated by bioassay-guided fractionation on VLC and preparative TLC. The structures of the compounds were determined by (1)H and (13)C NMR. Fractions were tested for affinity to the serotonin transporter in a binding assay using [(3)H]-citalopram as ligand. The IC(50) values of buphanidrine and buphanamine were 274 microM (K(i)=132 microM) and 1799 microM (K(i)=868 microM), respectively. The two alkaloids were also tested for affinity to the 5HT(1A) receptor, but only showed slight affinity.     

Alpha-1--antitrypsin in aqueous humour from patients with corneal allograft rejection

PURPOSE: To investigate the presence and concentration of alpha1-antitrypsin in aqueous humour at the time of corneal rejection and to compare results obtained from patients with reversible and irreversible rejection. METHODS: Samples of aqueous humour were obtained from 17 patients with acute corneal endothelial allograft rejection. The presence of alpha1-antitrypsin in aqueous humour was confirmed by immunoblotting and measured employing a sandwich ELISA. Total protein concentrations in aqueous humour were measured using Bradford's method. The outcome of corneal rejection episodes was determined 1 month after diagnosing corneal rejection and described as reversible or irreversible rejection. RESULTS: alpha1-antitrypsin was detected in aqueous humour. Patients with reversible rejection had significantly higher alpha1-antitrypsin concentration than patients with irreversible rejection (p = 0.044). There was no significant difference in total protein concentrations (p = 0.745), and no correlation was found between alpha1-antitrypsin and total protein concentrations (p = 0.368). CONCLUSIONS: alpha1-antitrypsin in aqueous humour seems to signal a favourable outcome of corneal rejection. The possible mechanism is discussed.     

Assessment of HIV-1 patient recruitability in the Republic of Guinea-Bissau using African versus North American hematology and biochemistry reference intervals

Hematology and biochemistry reference intervals have been derived from healthy, HIV-negative populations to guide clinical trials worldwide. However, it is less clear how such values may be applied to clinical trials involving HIV-infected individuals. We show that contradictory interpretations about patient recruitability are reached when applying African versus North American reference intervals to an HIV-1 cohort in Guinea-Bissau. These observations underscore the need to question non-African guidelines in the context of HIV intervention clinical trials in Africa.