Current management of ectopic pregnancy

Ectopic pregnancy continues to be one of the most common gynecologic emergencies and is the leading cause of pregnancy-related first-trimester death in the United States. The rate of ectopic pregnancy continues to rise because of increases in the incidences of its risk factors. However, improved modalities of early diagnosis and treatment have reduced both mortality and morbidity of this condition. In this article, the authors present an evidence-based review of the risk factors and presentation of ectopic pregnancy, including the utility of various diagnostic techniques, and compare the appropriateness and effectiveness of different therapeutic approaches.     

Pathological,molecular, and clinical characteristics of cholangiocarcinoma: A comprehensive review

Cholangiocarcinomas are a heterogeneous group of highly aggressive cancers that may arise anywhere within the biliary tree. There is a wide geographical variation with regards to its incidence, and risk-factor associations which may include liver fluke infection, primary sclerosing cholangitis, and hepatolithiasis amongst others. These tumours are classified into intrahepatic, perihilar and distal based on their anatomical location. Morphologically, intrahepatic cholangiocarcinomas are further sub-classified into small and large duct variants. Perihilar and distal cholangiocarcinomas are usually mucin-producing tubular adenocarcinomas. Cholangiocarcinomas develop through a multistep carcinogenesis and are preceded by dysplastic and in situ lesions. While clinical characteristics and management of these tumours have been extensively elucidated in literature, their ultra-structure and tumour biology remain relatively unknown. This review focuses on the current knowledge of pathological characteristics, molecular alterations of cholangiocarcinoma, and its precursor lesions (including biliary intraepithelial neoplasia, intraductal papillary neoplasms of the bile duct, intraductal tubulopapillary neoplasms and mucinous cystic neoplasm).     

Induced aflatoxicosis in rabbits: blood coagulation defects

The effect of acute and subchronic experimental aflatoxicosis on blood clotting activity and platelets was evaluated. Male New Zealand White rabbits (weighing 2.4-3.2 kg each) were used. In Experiment 1, 19 rabbits were given orally 0.05 mg of aflatoxin B1 (AFB1)/kg of body weight daily from Day 0 through Day 23. Blood samples were collected before dosing and on Days 2, 5, 9, 12, 16, 19, and 23 of the experimental period. In Experiment 2, 40 rabbits were given a single dose of 0.4 mg of AFB1/kg of body weight. Blood samples were collected before dosing and at 12, 24, 36, and 48 hr after dosing. When compared to baseline and control animal values, one-stage prothrombin times and activated partial thromboplastin times of aflatoxin-dosed rabbits were lengthened, and there was a statistically significant decrease in fibrinogen, Factor IX, VIII, and V activities. Platelet counts were significantly increased in subacutely exposed rabbits, and platelet size was decreased in single high-dose treated groups. Factor deficiencies were attributed to a combination of decreased factor synthesis from hepatic insufficiency and consumptive coagulopathy or primary fibrinolysis.     

Massive ovarian edema mimicking an ovarian neoplasm in a patient with IVC web

Massive ovarian edema is an uncommon benign condition affecting young females predominantly those in the child bearing age group and preadolescent girls. Its clinical and radiologic overlap with ovarian neoplasms and torsion which require surgical intervention makes it imperative for the radiologist to consider this entity preoperatively as preserving fertility is vital in this young age group. We report a case of massive ovarian edema, a rare presentation in a patient with inferior vena cava web and consequent Budd Chiari Syndrome, an association previously unreported in literature.     

Use of rosiglitazone and pioglitazone immediately after the cardiovascular risk warnings

BackgroundMeta-analyses of oral hypoglycemic agents (OHAs) revealed that rosiglitazone increased the risk of myocardial infarction (MI) and heart failure (HF) and that pioglitazone increased the risk of HF and decreased the risk of MI.ObjectiveTo characterize the change in the pattern of use of OHAs immediately after the publication of these meta-analyses on May 21, 2007.MethodsPharmacy and medical claims data for a managed care organization were analyzed for patients continuously enrolled from January 1, 2005, to November 30, 2007, with at least 1 pharmacy claim for OHA in the 13-month period between November 1, 2006, and November 30, 2007. A 5-month pre-publication period (November 1, 2006, through March 31, 2007) was compared with a 5-month post-publication period (July 1, 2007, through November 30, 2007) using a differences-in-differences multinomial logistic regression. This regression explored discontinuation; continuation with monotherapy or adding another drug; and switching to a drug different from the index monotherapy drug after adjusting for gender, age, type of insurance, past 1-year history of MI or HF, and risk factors for MI and HF in the past 1 year.ResultsThe relative rate of switching to nonindex drug in the postpublication relative to prepublication was 2.64 (P = .046) for monotherapy rosiglitazone users and 0.72 (P = .583) for monotherapy pioglitazone users. The differences-in-differences estimate of the rate of switching to nonindex drugs for monotherapy rosiglitazone users was 3.64 (P = .090) times higher relative to the estimate for monotherapy pioglitazone users.ConclusionThe pattern of use differed fundamentally between monotherapy rosiglitazone users and users of all other monotherapy OHAs in the postperiod. Not only were monotherapy rosiglitazone patients switching to non-rosiglitazone drugs at a higher rate, but the rate also was more than 3 times higher than similar switches among monotherapy pioglitazone users in the postperiod relative to the preperiod. This shows that the market response as observed by patient/prescriber decisions to the adverse news was interpreted narrowly to monotherapy rosiglitazone, and there is little or no spillover to the other drugs. Therefore, this study found that there was a differential effect of meta-analyses on the use of the 2 drugs.     

Role of Vocal Cord Function and Dysfunction in Patients Presenting with Symptoms of Acute Asthma Exacerbation

A total of 48 patients presenting to the emergency department as acute asthma exacerbation were prospectively studied. Rhinolaryngoscopy was conducted with simultaneous flow measurements and spirometry performed before and after the procedure. Measurements of the vocal cord opening during various phases of respiration were analyzed. Only 4 of 48 patients had anterior two-thirds closure of the vocal cords with a diamond-shaped opening posteriorly during expiration. One additional patient had inspiratory and expiratory closure of the vocal cords. The previously unreported high incidence of anterior two-thirds closure (10.4%) of the vocal cords suggests that the upper airway has a role to play in a significant number of patients presenting with symptoms of asthma exacerbation.     

Does one size fit all? Adaptive radiotherapy for bladder cancer: A feasibility study

IntroductionAdaptive techniques to deliver radiotherapy to the bladder may ensure treatment accuracy whilst sparing organs at risk. This study assesses the frequency of when an alternative plan to the current standard may be beneficial and establish the treatment resource implications of adaptive techniques. Assess the variation in accuracy of skeletal surrogate compared to the target. Additionally describes a training package for therapeutic radiographers evaluating CBCT datasets for adaptive techniques.MethodsA library of three plans was created for each patient, small, standard and large. Weekly CBCT and planar imaging data were acquired from 10 bladder cancer patients receiving radical radiotherapy. Bladder volumes from weekly CBCT were compared to the planning scan. Image registration was performed using bone and soft tissue structures on the CBCT images. A database of images was created to develop competency assessment and a training package.ResultsMatching to a skeletal surrogate may under estimate movement of the target. Bladder volume can vary significantly during the course of treatment, even in the presence of bladder preparation protocols. The additional time required to implement this technique is 4 min per fraction compared to standard treatment with planar imaging.ConclusionsThis feasibility study is a useful process to facilitate the implementation of adaptive techniques. However a limitation of this study is the low number of CBCT datasets evaluated. The advent of IGRT and adaptive techniques gives increased confidence to reduce margins, consequently facilitating hypo-fractionation, and may provide a gain in linear accelerator efficiency and reduce the number of hospital visits for the patient. CBCT paired with a development programme for therapeutic radiographers is an effective and efficient means of implementing adaptive radiotherapy.