Labor induction

Labor induction has become commonplace in modern obstetrics. The increasing rate of labor induction has probably played a role in the increased rate of cesarean delivery observed in the United States during the past few decades. Clearly, the favorability of the cervix has a substantial impact on the potential success of any labor induction. Induction in the setting of an unfavorable cervix can result in prolonged induction, prolonged hospitalization, failed induction, and an increased cesarean delivery rate. In this modern era of healthcare reform and cost containment, the identification of therapeutic strategies to enhance the success and cost-effectiveness of labor induction are of great interest. Ongoing research is needed to advance our knowledge of the mechanisms of parturition and cervical ripening in order to direct interventions for labor induction more effectively.     

Fetal but not adult Leydig cells are susceptible to adenoma formation in response to persistently high hCG level: a study on hCG overexpressing transgenic mice

We have previously demonstrated that male transgenic (TG) mice overexpressing human chorionic gonadotropin (hCG+) develop reproductive organ defects, but no tumors, in adult age. In this study, the effects of persistently elevated hCG were followed in TG males between day 5 postpartum and adulthood. Leydig cell (LC) adenomas were found in prepubertal mice, most prominently at the age of 10 days, but not in adult age. Serum testosterone concentrations were significantly increased in TG males at all ages studied. The phenotype of the prepubertal hCG+ males resembled that found in boys upon expression of constitutively activating luteinizing hormone (LH) receptor mutations. The temporal expression patterns of the fetal LC marker gene, thrombospondin 2, and those of adult LCs, hydroxysteroid dehydrogenase-6, delta5-3-beta and prostaglandin D synthase, were similar in wild-type and hCG+ males. Hence, the postnatal adenomas resemble functionally fetal LCs, and only these cells are susceptible to hCG-induced tumorigenesis. Our findings demonstrate a novel intriguing difference between the fetal and adult LC populations and provide further insight into the potential tumorigenic effects of gonadotropins.     

An unusual fracture of the talus in a snowboarder

Fractures of the talus are uncommon. However, snow- boarding and skateboarding are 2 activities that are specifically associated with talus fractures. These patients sustain occult lateral talus process fractures that present as a severe ankle injury. The diagnosis is difficult because of subtle clinical and plain radiographic findings. Computed tomography is a very useful tool for the assessment of these injuries. Although the majority of these athletes have lateral sided talus fractures, there are variants. We present an unusual case of a displaced intra-articular fracture of the subtalar joint involving the middle articular facet of the talus with extension of the fracture into the talar head. This highlights the importance of carefully assessing snowboarders' "ankle injuries."     

Classification of the external auditory canal cholesteatoma

OBJECTIVES/HYPOTHESIS: The external auditory canal cholesteatoma (EACC) is a rare disease in the field of otolaryngology. Only 1 in 1,000 new otologic patients present with this entity, which was first described by Toynbee. The aim of this article is to classify EACC by different histopathologic and clinical findings of patients presenting to the Department of Otolaryngology at the University of Mannheim, Germany. METHODS: From 2000 to 2004, 17 patients presented to our clinic with EACC. The cholesteatoma were treated surgically, and the specimens were investigated histologically. Clinical findings were also recorded. We classified four stages: stage I with hyperplasia of the canal epithelium, stage II including periosteitis, Stage III including a defective bony canal, and stage IV showing an erosion of adjacent anatomic structure. RESULTS: Eight patients presented with stage II, five patients with stage III, three with stage I, and only one patient presented with erosion of the mastoid cells, which was determined as stage IV. CONCLUSION: In summary, our classification serves to describe the different histopathologic and clinical stages of EACC.     

Service use and outcomes of first-admission patients with psychotic disorders in the Suffolk County Mental Health Project

OBJECTIVE: The purpose of the study was to examine the inpatient and outpatient service use and 4-year outcomes of newly admitted psychotic patients during a period of rapid change in the provision of psychiatric services in a well-defined catchment area in New York State in the 1990s. METHOD: Subjects were 573 participants of the Suffolk County Mental Health Project. This group comprised patients with psychotic disorders first admitted between September 1989 and August 1995 to 12 inpatient facilities across Suffolk County, N.Y., and followed for up to 48 months. The subjects' service use, course of illness, symptomatic outcomes, suicide risk, homelessness risk, and satisfaction with care were compared across admission years. RESULTS: The length of inpatient stays decreased significantly across the years. However, the number of outpatient visits and therapy sessions did not vary. Although the patients admitted in later years were more symptomatic at admission to their first hospitalization, their course and outcomes over the follow-up period were not worse and they were not less satisfied with their care, compared with the patients admitted in earlier years. CONCLUSIONS: The clinical characteristics of patients and the role of inpatient care in the management of patients with psychotic disorders gradually changed during the 1990s. These changes, however, were not associated with changes in the use of outpatient services or outcomes. Nevertheless, shorter hospital stays and the presence of more severely ill patients highlight the need for more attention to linkage to aftercare and enhancement of support networks in the community.     

Contemporary management of preterm premature rupture of membranes (PPROM): a survey of maternal-fetal medicine providers

OBJECTIVE: This study was undertaken to characterize variations in the management for women with preterm premature rupture of membranes (PPROM) among maternal-fetal medicine (MFM) specialists in the context of current recommendations for clinical practice and evidenced-based practice. STUDY DESIGN: We performed a Web-based survey of 1375 MFM providers. Participants were queried on practice characteristics and management issues including use of tocolytics, antibiotics, steroids, and timing of delivery. RESULTS: A total of 508 providers (37%), representing all 50 states and 13 countries, responded to the survey. Only 30% reported a formal departmental protocol for managing women with PPROM. Consistent use of steroids (99.4%) and antibiotics (99.6%) were reported. Administration of steroids was confined to < or =32 weeks by 37%, and < or =34 weeks by 51% of practitioners. Repeated dosing of steroids was uncommon (16%). The antibiotics use and rationale for use varied among respondents. Tocolytics were used by 73% of respondents with magnesium sulfate the main agent used (98%). Use of tocolytics was generally used for 48 hours or less to attain steroid benefit (88%). Amniocentesis was used by 66% of practitioners in the acute evaluation of PPROM. Fetal lung maturity testing was reported by 78% with variability noted with respect to the test used. Outpatient management of women with PPROM after viability was noted by 43% of respondents. Gestational age at which expectant management is abandoned in women with PPROM varied significantly between respondents: > or =34 weeks by 56%, > pr =35 weeks by 26%, > or =36 weeks by 12%, and > or =37 weeks by 4.0%. CONCLUSION: Although many management practices for women with PPROM are consistent with currently available evidence and practice recommendations, substantial variations still exist among MFM providers.