Laparoscopic Management of Adnexal Masses

Retrospective study of 121 cases of adnexal masses which were managed laparoscopically was carried out. The aim of study was to evaluate the safety and effectiveness of laparoscopic management of adnexal masses. In 120 cases, procedure was completed safely with minimum morbidity. In one case laparotomy had to be done to complete the procedure. In 76 cases cystectomy was done, 26 required salpingo-oophorectomy and 19 required only salpingectomy. Histologic evaluation revealed 30 functional cysts, 36 endometriotic cysts, 11 dermoids, 9 serous cystadenomas, 3 mucinous cystadenomas, 11 parovarian cysts, 19 cases of hydrosalpinx and 2 cases of tuberculosis.Key Words: Adnexal mass, Laparoscopy, Ovarian cyst     

Isolated prehospital hypotension after traumatic injuries: a predictor of mortality?

In patients with traumatic injuries, prehospital hypotension that resolves by Emergency Department (ED) arrival is of uncertain significance. We examined the impact of prehospital hypotension (PH) in normotensive ED patients with traumatic injuries on predicting mortality and chest/abdominal operative intervention. A retrospective cohort study was conducted of consecutive patients undergoing helicopter transport to two trauma centers between 1993 and 1997. Outcomes were mortality and chest or abdominal operative intervention. Of 545 scene transports, 55 (10.1%) patients were hypotensive on ED arrival, leaving 490 normotensive ED patients. Of 490 patients, 35 (7%) had PH and 455 (93%) had no PH. Multiple logistic regression showed the PH group to have a relative risk for death of 4.4 (95% CI: 1.2-16.6, p < 0.03) and for chest or abdominal operative intervention of 2.9 (1.1-7.6, p < 0.03). In this study of normotensive trauma center patients, prehospital hypotension was associated with increased risk of mortality and significant chest or abdominal injury.     

Enteric nerves and interstitial cells of Cajal are altered in patients with slow-transit constipation and megacolon

BACKGROUND & AIMS: A variety of gastrointestinal motility disorders have been attributed to alterations of interstitial cells of Cajal and malformations of the enteric nervous system. This study evaluates both the distribution of interstitial cells of Cajal and the pathohistology of the enteric nervous system in 2 severe human colorectal motility disorders. METHODS: Colonic specimens obtained from patients with slow-transit constipation (n = 11), patients with megacolon (n = 6), and a control group (n = 13, nonobstructing neoplasia) were stained with antibodies against c-kit (marker for interstitial cells of Cajal) and protein gene product 9.5 (neuronal marker). The morphometric analysis of interstitial cells of Cajal included the separate registration of the number and process length within the different regions of the muscularis propria. The structural architecture of the enteric nervous system was assessed on microdissected whole-mount preparations. RESULTS: In patients with slow-transit constipation, the number of interstitial cells of Cajal was significantly decreased in all layers except the outer longitudinal muscle layer. The myenteric plexus showed a reduced ganglionic density and size (moderate hypoganglionosis) compared with the control group. Patients with megacolon were characterized by a substantial decrease in both the number and the process length of interstitial cells of Cajal. The myenteric plexus exhibited either complete aganglionosis or severe hypoganglionosis. CONCLUSIONS: The enteric nervous system and interstitial cells of Cajal are altered concomitantly in slow-transit constipation and megacolon and may play a crucial role in the pathophysiology of colorectal motility disorders.     

Abnormalities of the enteric nervous system in heterozygous endothelin B receptor deficient (spotting lethal) rats resembling intestinal neuronal dysplasia

BACKGROUND: A homozygous mutation of the endothelin B receptor (EDNRB) gene in spotting lethal (sl/sl) rats leads to Hirschsprung's disease (HSCR) with long segmented aganglionosis. However, the effects on the development of the enteric nervous system (ENS) promoted by a heterozygous mutation of the EDNRB gene are not known. The present study aimed to describe and morphometrically assess the phenotypic abnormalities of the ENS in heterozygous (+/sl) EDNRB deficient rats in comparison with homozygous (sl/sl) EDNRB deficient and wild-type (+/+) rats. METHODS: The distal small intestine, caecum, and colon were obtained from sl/sl, +/sl, and +/+ rats. To demonstrate the three dimensional organisation of the ENS, the intestinal wall was microdissected into wholemounts and incubated against the pan-neuronal marker protein gene product 9.5. Assessment of the ENS included morphometric quantification of ganglionic size and density, the number of nerve cells per ganglia, and the diameter of nerve fibre strands within both the myenteric and submucous plexus. RESULTS: Sl/sl rats were characterised by complete aganglionosis resembling the same histopathological features observed in patients with HSCR. +/sl rats revealed more subtle abnormalities of the ENS: the submucous plexus was characterised by a significantly increased ganglionic size and density, and the presence of hypertrophied nerve fibre strands. Morphometric evaluation of the myenteric plexus did not show statistically significant differences between +/sl and +/+ rats. CONCLUSIONS: In contrast with sl/sl rats, +/sl rats display non-aganglionated malformations of the ENS. Interestingly, these innervational abnormalities resemble the histopathological criteria for intestinal neuronal dysplasia (IND). Although IND has been described in several intestinal motility disorders, the concept of a clearly defined clinical-histopathological entity is still controversially discussed. The present findings support the concept of IND based on clearly defined morphological criteria suggesting a genetic link, and thus may provide a model for human IND. Furthermore, the data underline the critical role of the "gene dose" for the phenotypic effects promoted by the EDNRB/EDN3 system and confirm that the development of the ENS is not an "all or none" phenomenon.     

Use of pulse oximeter for determining distal perfusion in neonates &; infants with suspected vascular compromise

Conclusion The use of a pulse oximeter, which is readily available in the ICU, can be of immense benefit to determine the status of distal limb perfusion in neonates and children who are suspected of having a vascular compromise, and the pulsations cannot be appreciated due to the presence of limb edema. Limb warmth and capillary filling are the primary indicators of vascularity but may be misleading in some patients. The presence of poor quality tracings or absent tracings is a definite indicator of significant ischemia. The use of a pulse oximeter, for determination of oxygen saturation, was declared by Severinghaus and Astrup to be “arguably the most significant technologic advance ever made in monitoring the well being of patients during anaesthesia, recovery and critical care. Perhaps the use of the pulse oximeter for determination of distal perfusion can further augment the statement. Editor Note The authors are to be congratulated for their observations which are clinically relevant. However we urge them to continue their study and obtain meaningful data, with proper statistical analysis. For the time being these observations may be considered preliminary.     

A Training Aid for IV Access

Starting intravenous drip is one of the first steps in the treatment of a patient. Training is the key to attain proficiency to get intravenous access.Key Words: Intravenous access, Training aid     

Socioeconomic status and mortality in Swedish women: opposing trends for cardiovascular disease and cancer

We examined relations between socioeconomic status and cardiovascular disease, cancer, and diabetes mellitus in a 24-year prospective study of 1,462 Swedish women. Two socioeconomic indicators were used: the husband's occupational category for married women and a composite indicator combining women's educational level with household income for all women. The husband's occupational category was strongly associated with cardiovascular disease and cancer mortality in opposite directions, independent of age and other potential confounders. Women with husbands of lower occupational categories had an increased risk of cardiovascular disease mortality [relative risk (RR) = 1.60; 95% confidence interval (95% CI) = 1.09-2.33] while experiencing lower rates of all-site cancer mortality (RR = 0.69; 95% CI = 0.50-0.96). A similar relation was seen with the composite variable: women with low socioeconomic status had an increased risk of cardiovascular disease (RR = 1.37; 95% CI = 1.01-1.84) but a somewhat lower risk for cancer of all sites (RR = 0.86; 95% CI = 0.66-1.11). Finally, morbidity data (diabetes mellitus, stroke, and breast cancer) yielded results that were consistent with the mortality trends, and breast cancer appeared to account for a major part of the association between total cancer and high socioeconomic status. In summary, higher socioeconomic status was associated with decreased cardiovascular disease mortality and excess cancer mortality, in such a way that only a weak association was seen for all-cause mortality.     

Renal function and intensive lowering of blood pressure in hypertensive participants of the hypertension optimal treatment (HOT) study

This article reports further analyses of the Hypertension Optimal Treatment (HOT) Study data with the aim to describe (1) the value of baseline serum creatinine and its clearance (estimated by Cockroft and Gault formula) as predictors of cardiovascular events, (2) the effects of intensive lowering of BP on cardiovascular events and renal function in patients with reduced renal function, and (3) the effects on cardiovascular events of adding acetylsalicylic acid to antihypertensive therapy in patients with reduced renal function. The results show that (1) baseline elevation in serum creatinine and a reduction in estimated creatinine clearance are powerful predictors of cardiovascular events and death. (2) Reduced renal function at baseline did not preclude the desired control of BP. In contrast to patients with normal renal function, the incidence of major cardiovascular events did not differ in the three groups of patients with mild renal insufficiency randomized to different diastolic BP targets. No significant changes in serum creatinine were seen at the end of the 3.8-yr treatment period in the great majority of patients. However, there was a small group of patients (0.58% of the total study population) whose renal function deteriorated (increase > or =30% over baseline and final serum creatinine concentration > or =2 mg/dl) despite satisfactory reduction of diastolic BP. (3) The results of this reanalysis of the HOT Study suggest though do not prove that the association of acetylsalicylic acid with intensive antihypertensive therapy offers additional benefit in hypertensive patients with reduced renal function.