Transvaginal organ extraction: potential for broad clinical application

Background

Natural orifice transluminal endoscopic surgery procedures have evolved over the past few years. A transvaginal approach is a promising alternative for intraperitoneal procedures. Our objective was to evaluate the safety and feasibility of transvaginal organ extraction.

Methods

This institutional review board-approved protocol involved retrospective review of an ongoing prospective study. Female subjects who presented to our hospital for elective cholecystectomy, appendectomy, or sleeve gastrectomy were offered participation in the study. Eligible patients met the following criteria: age between 18 and 75, diagnosis of gallbladder disease, acute appendicitis, or morbid obesity who desired surgical treatment. A hybrid transvaginal natural orifice approach was used in this series.

Results

Thirty-four women underwent transvaginal organ extraction between September 2007 and January 2012. The mean age was 40 ± 12.1 years (range 23–63 years). The mean body mass index was 27 ± 6.4 kg/m² (range 16–43 kg/m²). All patients had an American Society of Anesthesiologists classification of two or below. The mean operative time for cholecystectomy, appendectomy, and sleeve gastrectomy was 90, 71, and 135 min, respectively. There were no conversions to open operation and no intraoperative complications. The mean hospital stay was 2 days for all cases. Patients were followed for a mean of 24 months (range 1–61 months). There were two pregnancies and two successful vaginal deliveries. Six patients (18 %) had minor complaints of spotting or heavy menses in the immediate postoperative period that resolved with conservative measures. There were no abdominal wall complications. There were no long-term complications and no mortalities.

Conclusions

This initial experience suggests that this surgical approach is safe, does not increase length of stay, and has no long-term vaginal complications. Given this attractive profile, a transvaginal approach may prove to be a superior mode of organ extraction, although randomized studies and long-term follow-up are needed.     

Clinical competency evaluation of Brazilian chiropractic interns

ObjectiveThis study compares the results of an objective structured clinical examination (OSCE) between 2 groups of students before an internship and after 6 months of clinical practice in an internship.MethodsSeventy-two students participated, with 36 students in each cohort. The OSCEs were performed in the simulation laboratory before the participants'' clinical practice internship and after 6 months of the internship. Students were tested in 9 stations for clinical skills and knowledge. The same procedures were repeated for both cohorts. The t test was used for unpaired parametric samples and Fisher''s exact test was used for comparison of proportions.ResultsThere was no difference in the mean final score between the 2 groups (p = .34 for test 1; p = .08 for test 2). The performance of the students in group 1 was not significantly different when performed before and after 6 months of clinical practice, but in group 2 there was a significant decrease in the average score after 6 months of clinical practice.ConclusionsThere was no difference in the cumulative average score for the 2 groups before and after 6 months of clinical practice in the internship. There were differences within the cohorts, however, with a significant decrease in the average score in group 2. Issues pertaining to test standardization and student motivation for test 2 may have influenced the scores.Key Indexing Terms: Chiropractic, Internship, Measurement, Educational     

Diabetic retinopathy screening with non-mydriatic retinography by general practitioners: 2-year results

AimsTo ascertain in real practice the diagnosis rate of diabetic retinopathy (DR) in patients considered to have positive screening test by general practitioners (GPs) and what are the reasons for the false positive diagnosis.MethodsFour GPs previously instructed in the interpretation of retinal photographs evaluated the digital retinography images of patients with diabetes obtained during a 2-year period. When the images were considered normal, a new appointment was scheduled for 1 year later and a report was emailed to the referring physician. Patients with any sign of DR or other suspicious retinal alterations and those whose images were considered difficult or impossible to assess were referred to an ophthalmologist.ResultsA total of 2750 patients were referred for screening. The images of 2036 (74%) patients were considered normal, and the images of 714 (26%) patients were sent to ophthalmologists. Among the referred patients, 392 (55%) did not have DR, 244 (34%) had DR, and 78 (11%) had unreadable images. The retinal images of 240 patients whose fundi were considered normal were read again by ophthalmologists to evaluate false negatives. Of them, 16 patients (7%) had DR but only two patients (1%) had treatable DR.ConclusionsAfter adequate training, GPs can screen for DR with a high level of accuracy using non-mydriatic retinography. There is a need to strengthen the training of GPs in order to recognize non-visual threatening abnormalities.     

The putative link between the MMR vaccine and autism and refusal to vaccinate

The paper of Wakefield et al. in The Lancet, triggered a negative reaction to the MMR vaccine, even though it was just a series of cases and the association between vaccination and autism could well be anecdotal. However, it was found that this association was spurious, not only because of hidden biases but also to alterations of the data and other improper behavior of the two authors that they were expelled from medical council. Finally, the article was removed from the magazine. This episode invites to think about the credibility and trust in the authorities and professionals to the population, as well as the suspicions that may arise when there are potential conflicts of interest among professionals, industry magazines and the population. A special area of interest is on the distorted expectations of health interventions, including vaccination, particularly with regard to both individual and collective prevention.     

Image analysis of the AgNOR response in ras-transformed human breast epithelial cells

The argyrophylic staining of the nucleolar organizer regions (AgNOR positive response) in interphase nuclei is often related directly to the cellular demand for ribosome biogenesis and is considered of relevance in studies of tumor pathology. Transformation of human breast epithelial MCF-10A cells by the c-Ha-ras oncogene results in altered growth, invasiveness and tumorigenicity in nude mice. Since ras transformation may be associated with a more intense nucleolar activity, we examined the influence of transfection by the Ha-ras oncogene on AgNOR staining response in MCF-10A cells. Following assessment of the AgNOR response with video image analysis, the AgNOR-positive areas and the AgNOR area/nuclear area ratio, but not the number of AgNOR aggregates or dots per nucleus, were found to be much higher after ras transformation. A role of the Ha-ras transformation on the nucleolar activity of the MCF-10A is thus suggested as assessed by the AgNOR staining. Based on data in the literature, it is also hypothesized that a decreased wild-type p53 level, possibly promoted by the ras transformation, may be associated with the increased AgNOR response.