Intracervical versus vaginal misoprostol for cervical dilatation prior to operative hysteroscopy—a comparative study

Background

Hysteroscopic surgery requires pre-operative cervical ripening to facilitate adequate dilatation of the cervix for insertion of operative hysteroscope. This study was conducted to compare the efficacy of intracervical misoprostol with vaginal misoprostol in achieving cervical ripening before operative hysteroscopy.

Methods

In this randomised comparative study conducted at a tertiary care teaching hospital, 56 patients needing operative hysteroscopy were divided into two groups of 28 patients, one for intracervical misoprostol and the other for vaginal misoprostol. Four hundred microgram of misoprostol was inserted on the night before and in the morning of operative hysteroscopy intracervically in group I and vaginally in group II.

Results

Primary outcome measure was number of patients achieving 7 mm preoperative dilatation of cervix. Largest Hegar dilator that could be passed into the uterine cavity past the internal optic sheath without resistance was noted in each case. Mean cervical dilatation prior to operative hysteroscopy was calculated. In addition, incidence of slipping of vulsellum and cervical laceration was also noted. Time to achieve full cervical dilatation was recorded. In 23/28 cases of group I and 5/28 in group II, size 7 Hegar dilator could be passed without effort. Mean cervical dilatation was 7.5 mm in group I and 5.7 mm in group II. Slipping of the vulsellum and cervical lacerations were seen in significantly less patients in group I. Mean time to achieve cervical dilatation to 10 mm was 43.39 seconds in group I and 103.96 seconds in group II (P<0.0001).

Conclusion

Intracervical administration of misoprostol is an effective method of achieving cervical ripening for easy cervical dilatation up to 10 mm prior to operative hysteroscopy.Key Words: cervical ripening, intracervical administration, misoprostol, operative hysteroscopy     

Psychosocial impact of Von Hippel–Lindau disease: levels and sources of distress

Lammens CRM, Bleiker EMA, Verhoef S, Hes FJ, Ausems MGEM, Majoor‐Krakauer D, Sijmons RH, Luijt van der RB, Ouweland van den AMW, Van Os Tam, Hoogerbrugge N, Gomez‐Garcia EB, Dommering CJ, Gundy CM, Aaronson NK. Psychosocial impact of von Hippel–Lindau disease: levels and sources of distress. Von Hippel–Lindau disease (VHL) is a hereditary tumor susceptibility syndrome, characterized by an increased risk of developing multiple benign and malignant tumors at various sites and ages with limited preventive options. This study evaluates the prevalence of distress among VHL family members and factors associated significantly with such distress. Forty‐eight families with a VHL mutation were identified via the nine family cancer clinics in the Netherlands. In total, 171 family members (carriers, 50% at‐risk, non‐carriers) were approached, of whom 123 (72%) completed a self‐report questionnaire. Approximately 40% of the VHL family members reported clinically relevant levels of distress, approaching 50% among the carriers and, possibly even more striking, 36% among the non‐carriers. Having lost a first degree relative due to VHL during adolescence (OR 11.2; 95% CI 1.4–86.9) was related significantly to heightened levels of distress. Approximately, only one‐third of those who reported heightened levels of distress had received professional psychosocial support. A substantial percentage of family members experience clinically relevant levels of distress. We would recommend the introduction of a procedure for screening for distress in this vulnerable population. Special attention should be paid to those individuals who have lost a close relative due to VHL during adolescence.     

Fournier’s gangrene in a five year old boy – beware of the child post varicella infection

Scrotal pain and swelling are common presentations in children and are usually secondary to torsion of the testis, hydatid of Morgagni or epididymo-orchitis. Fournier’s gangrene is a rare, but life-threatening disease, that can present in a similar fashion. We present a rare case of Fournier’s gangrene in a 5-year-old boy associated with a preceding varicella rash.     

Secular trend in the sexual maturation of Southern Chinese girls

In 1993, a cross-sectional study of sexual maturation of normal Chinese schoolgirls was performed in Hong Kong. The aim of the study was to obtain an up-to-date reference for normal pubertal development in Chinese girls. Breast development was assessed in 3749 girls aged 7–19 y, and pubic hair rating was assessed in 3745 girls. Menstrual status was recorded in 6467 girls over 6 y of age. The median age of onset of puberty as indicated by breast stage II or above was 9. 78 (95% CI 9. 70–9. 85) y. The median age of onset of pubic hair development was 11. 64 (95% CI 11. 56–11. 72) y. The median age of menarche was 12. 38 (95% CI 11. 98–12. 78) years. Percentile values for the age at which each puberty staging appeared were constructed and incorporated into the height-for-age charts. When comparison is made with similar studies done in 1962 and 1979, a significant downward secular trend in sexual maturation is observed ( p < 0. 01). Except for breast development the downward secular trend in sexual maturation appears to be diminishing and may be coming to a halt in the Chinese girls in Hong Kong. Their median ages of sexual maturation are now among one of the earliest medians recorded in the world population studied.     

Abdominal migraine: A childhood syndrome defined

It has long been recognized that some cases of recurrent abdominal pain in children are related to migraine, but the diagnostic criteria for abdominal migraine have not been defined. We have identified a group of children with recurrent abdominal pain who had a family history of migraine--in over half the cases in a first-degree relative--and who obtained marked relief from their symptoms from specific anti-migraine therapy. These children had a well-defined syndrome comprising episodes of midline abdominal pain of sufficient severity to interfere with normal activities and lasting for prolonged periods, frequently accompanied by pallor, headache, anorexia, nausea, and vomiting. It is proposed that these children have "abdominal migraine".     

Malignant rhabdoid tumour of the third ventricle

A 16‐year‐old boy presented to the All India Institute of Medical Sciences hospital with signs and symptoms of raised intracranial pressure. A CT scan showed obstructive hydrocephalus from a large posterior third ventricle mass lesion. The patient underwent a subtotal resection of the tumour, followed by radiotherapy. Histological, ultrastructural and immunohistochemical features of the tumour were consistent with primary malignant rhabdoid tumour. The age of presentation and location of the lesion were unusual.     

Isolated central canal rupture of spinal dermoid: Report of two cases

We report two cases of lumbar spinal dermoid cysts with asymptomatic rupture and migration of free fat droplets into the central canal. No fatty droplets were seen within the lumbar subarachnoid space. The presence of fat droplets within the central canal is unusual because the central canal is rudimentary in adults. We suggest that hydromyelia secondary to tumour and specific tumour morphology might facilitate the selective rupture of dermoids into the central canal. We recommend a follow up of these patients to detect any possible intracranial migration of fat droplets and resultant complications.     

IMMUNOLOGICAL MONITORING IN TRANSPLANTATION

Sixty eight patients who had undergone live related donor renal transplantation (LRD), were evaluated for soluble interleukin-2 receptors (sIL-2R), tumour necrosis factor alpha (TNF-α) and autoantibodies against IgG(Fab’)2 and IgG(Fc), at pre- and various post-transplant intervals. Serum sIL-2R levels were significantly elevated in hemodialysed patients awaiting transplantation (mean 259.2 ± 90.5 pmol/L) as compared to healthy volunteers (mean 52.6 ± 16.7 pmol/L). In 96 samples obtained from patients with well-functioning grafts (WFG), the post-transplant sIL-2R levels (135.6 ± 65.4 pmol/L) were significantly lower (p < 0.001) than their pretransplant values. Eight patients with cyclosporin-A (CsA) nephrotoxicity, 14 with reversible acute tubular necrosis (ATN) and 4 patients with partial surgical obstruction, revealed moderate levels (99.0 ± 13.7, 184.1 ± 47.5, 156.7 ± 40.4 pmol/L respectively). On the other hand, 29 patients with acute rejection episodes, 11 with chronic rejection and 8 with infections had significantly higher levels (307.9 ± 89.3, 253.3 ± 68.6,345 ± 110.6 pmol/L), (p < 0.001). TNF-α levels were also raised in rejection and infective episodes but were not statistically significant. Serum anti-IgG(Fab’)2 levels were found higher (0.407 OD) in WFG as compared to those with declining graft functions (0.279 OD). On the contrary high pre- and post-transplant anti-IgG(Fc) activity was associated with increased graft rejection and lower survival rate.KEY WORDS: Autoantibodies, Immunoglobulins, Kidney transplantation, Receptors, Interleukin-2, Transplantation immunology, Tumor necrosis factor     

Safety of ciprofloxacin therapy in children: magnetic resonance images, body fluid levels of fluoride and linear growth

We evaluated the safety of ciprofloxacin administered in a dose of 15–25 mg/kg for 9–16 days, in a case series of 58 children who were between 8 months and 13 years of age. No arthropathy was observed during therapy and follow–up. Blinded evaluation of 22 pairs of nuclear magnetic resonance scans obtained before and between day 10 and 15 of therapy did not reveal any cartilage damage. After the first dose of ciprofloxacin (10 mg/kg), serum fluoride levels increased at 12 h in 15 of 19 (79%) patients; 24–h urinary fluoride excretion was higher on day 7 compared with basal values in 16 of 18 (88.9%) patients. Height z scores of 53 patients at a mean of 22.5 months of follow–up were not significantly different from basal scores ( p = 0.12). In conclusion, ciprofloxacin may be recommended for use in children for short duration when effective alternative antibacterials are unavailable. However, there is a need for further studies to evaluate the tissue accumulation of fluoride and its potential to cause toxic effects.