Management of colostomal hemorrhage resulting from portal hypertension

Colostomy and ileostomy stomal hemorrhage is a rare and potentially fatal complication of portal hypertension. We describe two patients with colostomy stomal hemorrhage who had both undergone abdominoperineal resection for carcinoma of the rectosigmoid colon. Patient 1, in the absence of metastatic disease with minimal to moderate functional hepatic impairment, underwent a mesocaval interposition graft shunt and had no recurrence of stomal hemorrhage during the fourmonth postoperative period. Patient 2, in the presence of metastatic disease to the lungs and liver, was not shunted and died of hepatic and renal failure. Angiography, in particular splenopor-tography, is extremely helpful in establishing the diagnosis of portal hypertension and planning appropriate operative procedure. We reviewed the literature on ileostomy and colostomy hemorrhage in the presence of portal hypertension and conclude that control of major stomal hemorrhage by local measures is often ineffective and that portasystemic shunts may significantly improve long-term prognosis.     

Spatial Access to Sterile Syringes and the Odds of Injecting with an Unsterile Syringe among Injectors: A Longitudinal Multilevel Study

Despite the 2010 repeal of the ban on spending federal monies to fund syringe exchange programs (SEPs) in the USA, these interventions—and specifically SEP site locations—remain controversial. To further inform discussions about the location of SEP sites, this longitudinal multilevel study investigates the relationship between spatial access to sterile syringes distributed by SEPs in New York City (NYC) United Hospital Fund (UHF) districts and injecting with an unsterile syringe among injectors over time (1995–2006). Annual measures of spatial access to syringes in each UHF district (N = 42) were created using data on SEP site locations and site-specific syringe distribution data. Individual-level data on unsterile injecting among injectors (N = 4,067) living in these districts, and on individual-level covariates, were drawn from the Risk Factors study, an ongoing cross-sectional study of NYC drug users. We used multilevel models to explore the relationship of district-level access to syringes to the odds of injecting with an unsterile syringe in >75% of injection events in the past 6 months, and to test whether this relationship varied by district-level arrest rates (per 1,000 residents) for drug and drug paraphernalia possession. The relationship between district-level access to syringes and the odds of injecting with an unsterile syringe depended on district-level arrest rates. In districts with low baseline arrest rates, better syringe access was associated with a decline in the odds of frequently injecting with an unsterile syringe (AOR, 0.95). In districts with no baseline syringe access, higher arrest rates were associated with increased odds of frequently injecting with an unsterile syringe (AOR, 1.02) When both interventions were present, arrest rates eroded the protective effects of spatial access to syringes. Spatial access to syringes in small geographic areas appears to reduce the odds of injecting with an unsterile syringe among local injectors, and arrest rates elevate these odds. Policies and practices that curtail syringe flow in geographic areas (e.g., restrictions on SEP locations or syringe distribution) or that make it difficult for injectors to use the sterile syringes they have acquired may damage local injectors’ efforts to reduce HIV transmission and other injection-related harms.     

Detection of early placental hormone production in embryo transfer cycles lacking a corpus luteum

PurposeThis study sought to identify the initiation of placental hormonal production as defined by the production of endogenous estradiol (E2) and progesterone (P4) in a cohort of patients undergoing programmed endometrial preparation cycles with single embryo transfers resulting in live-born singletons.MethodsIn this retrospective cohort study, patients undergoing either programmed frozen-thawed embryo transfer (FET) with autologous oocytes or donor egg recipient (DER) cycles with fresh embryos were screened for inclusion. Only patients who underwent a single embryo transfer, had a single gestational sac, and a resultant live-born singleton were included. All patients were treated with E2 patches and intramuscular progesterone injections. Main outcome measures were serial E2 and P4, with median values calculated for cycle days 28 (baseline), or 4w0d gestational age (GA), through 60, or 8w4d GA. The baseline cycle day (CD) 28 median value was compared to each daily median cycle day value using the Wilcoxon signed rank test.ResultsA total of 696 patients, 569 using autologous oocytes in programmed FET cycles and 127 using fresh donor oocytes, from 4/2013 to 4/2019 met inclusion criteria. Serum E2 and P4 levels stayed consistent initially and then began to increase daily. Compared to baseline CD 28 E2 (415 pg/mL), the serum E2 was significantly elevated at 542 pg/mL (P < 0.001) beginning on CD 36 (5w1d GA). With respect to baseline CD 28 P4 (28.1 ng/mL), beginning on CD 48 (6w6d GA), the serum P4 was significantly elevated at 31.6 ng/mL (P < 0.001).ConclusionThese results demonstrate that endogenous placental estradiol and progesterone production may occur by CD 36 and CD 48, respectively, earlier than traditionally thought.     

Tubal Ectopic Pregnancy with Undetectable Initial Serum β-Human Chorionic Gonadotropin Level

We present a case of a tubal ectopic pregnancy (EP) in a patient with an initially undetectable serum β-human chorionic gonadotropin (β-hCG) level. A 33-year-old woman in a same-sex relationship underwent timed donor intrauterine insemination. Her serum β-hCG level was <5 mIU/mL 14 days after the intrauterine insemination. She reported menstrual bleeding 3 days after her negative pregnancy test and returned to the office 10 days later to begin a new treatment cycle. Her serum levels of estradiol, progesterone, and β-hCG were 119 pg/mL, 6.1 ng/mL and 1157 mIU/mL, respectively. Transvaginal ultrasonography did not show an intrauterine pregnancy. Her β-hCG level increased to 1420 mIU/mL the next day. She was diagnosed with a pregnancy of unknown location and treated with methotrexate. Her β-hCG levels continued to increase despite 3 methotrexate doses, necessitating laparoscopy. The diagnostic laparoscopy demonstrated approximately 100 mL of hemoperitoneum in the posterior cul-de-sac with an intact right fallopian tube that was dilated at its distal end by the EP. A total right salpingectomy was performed. Her β-hCG level was <5 mIU/mL 3 weeks later. The current case supports that although rare, an undetectable serum β-hCG level does not completely rule out the diagnosis of an EP.