Management of early viable cervical pregnancy

OBJECTIVE: To evaluate conservative management of early viable cervical pregnancy. DESIGN: Prospective study. SETTING: A tertiary teaching hospital. POPULATION: All cases of cervical pregnancies with fetal cardiac activity presenting to our hospital over six years. METHODS: All cases were managed with trans-abdominal intra-amniotic injection of 25 mg of methotrexate under ultrasound guidance. Follow up sonographic examinations and serum beta-hCG measurements were performed every three days. Cervical curettage was performed after two follow up ultrasound examinations had shown a dead fetus and a regressing gestational sac as well as declining beta-hCG levels. Patients were managed as outpatients. MAIN OUTCOME MEASURES: Successful management and need for hospitalisation. RESULTS: Nine cases were encountered. Two required a second injection of methotrexate for persistent fetal cardiac activity and serum beta-hCG rise in the follow up examination. We did not observe any side effects and no patient required admission to the hospital. CONCLUSIONS: Intra-amniotic methotrexate injection and subsequent cervical curettage after one week is a successful alternative for the management of cervical pregnancies.     

Is the occurrence of the empty follicle syndrome a predictor that a subsequent stimulated cycle will be an unfavourable one?

Several hypotheses have been advanced to explain empty follicle syndrome (EFS) but it remains a controversial topic. This paper reports experience with three IVF cycles in which no oocytes were collected. In all cases, an additional IVF cycle was performed. The ovarian stimulation protocol, ultrasound and hormonal surveillance methods, human chorionic gonadotrophin timing and oocyte retrieval technique were similar in all patients. The assessment of additional cycles demonstrated a poor response in terms of oocyte quality, since the number of mature oocytes was low despite the high number of oocytes collected. Thus, the data suggest that in these patients, EFS should be considered as a borderline form of poor response to ovarian stimulation. If this is confirmed, EFS should be a recurrent event and an empty cycle could be a good predictor that a subsequent stimulated cycle will be an unfavourable.     

The effect of investment material type on the contamination zone and mechanical properties of commercially pure titanium castings

STATEMENT OF PROBLEM: Different types of investment materials affect the formation of a surface contamination zone within commercially pure titanium (cpTi) castings. This contamination zone may possibly alter the mechanical properties of cast titanium, which may be problematic for castings used in the fabrication of removable and fixed prostheses. PURPOSE: The purpose of this study was to evaluate the effect of different types of investments on the extent of contamination zone and the modulus of elasticity, yield strength, elongation, and hardness of cpTi castings. MATERIAL AND METHODS: Forty wax patterns were fabricated according to ISO 9693 for tensile testing. The patterns were divided into 2 groups of 20 patterns each, invested, and cast in pairs using cpTi. The first group (P) was invested with a phosphate-bonded silica-based investment material (Ticoat S+L), and the second group (M), with a magnesia-alumina investment material (Rematitan Ultra). Investment materials were examined by x-ray diffraction analysis (XRD). One specimen from each group was sectioned and prepared for metallographic observation. The extent of the contamination zone was determined by scanning electron microscopy, using back-scattering electron imaging and energy dispersive spectroscopy analysis, as well as microhardness testing. The tensile strength of the specimens was determined in a universal testing machine. From the derived tensile curves, the modulus of elasticity, yield strength, and percentage elongation were calculated and statistically evaluated among the groups using the Student t test (alpha=.05). Three fractured specimens from each group were examined by scanning electron microscopy to determine the mode of fracture. RESULTS: XRD analysis showed that silica and magnesia were the dominant phases of Ticoat S+L and Rematitan Ultra, respectively. The contamination zone was found to extend 50 to 80 mum for the P specimens and 15 to 20 mum for the M specimens. No significance difference was found for the modulus of elasticity (P=85 +/- 11 GPa, M=79 +/- 13 GPa), whereas significant differences were found for the yield strength (P=462 +/- 48 MPa, M=321 +/- 54 MPa; P<.001) and percentage elongation (P=12 +/- 2, M=21 +/- 7; P=.002) between the groups tested. The fracture mode was brittle externally and ductile internally for both groups. CONCLUSIONS: According to the results of this study, the extent of the contamination zone as well as the yield strength and percentage elongation of the cpTi castings were significantly affected by the type of the investment material.     

Impact of capsule endoscopy in obscure small-bowel bleeding: defining strict diagnostic criteria for a favorable outcome

BACKGROUND: The most frequent indication for capsule endoscopy is to diagnose the cause of obscure GI bleeding. The objective of the study was to determine the impact of capsule endoscopy on the outcome of patients with GI bleeding of obscure origin. METHODS: Ninety-six patients (53 men, 43 women; mean [standard deviation] age, 60.84 years [16.55 years]) were enrolled in the study. All patients have been subjected to gastroscopy, colonoscopy, small-bowel barium follow-through or enteroclysis, and push enteroscopy; no bleeding site had been identified. Capsule endoscopy was performed with the Given M2A video capsule system. By using strict criteria, studies were classified as having positive findings, findings of uncertain significance, and no findings. Outcome was defined as continued or complete resolution of bleeding. RESULTS: Positive findings, findings of uncertain significance, and no findings were identified in 41.7%, 20.8%, and 37.5% of our study population, respectively. The most common lesions seen were angiodysplasias of the small intestine. Therapeutic intervention was possible in 82.5% of patients with positive findings and in 35.0% of patients with findings of uncertain significance. Complete resolution of bleeding, after a median (interquartile range) follow-up period of 14 months (9-17 months), occurred significantly more often in patients with positive findings (68.4%) compared with patients with findings of uncertain significance and no findings (40.8%, p = 0.009). CONCLUSIONS: Capsule endoscopy increases the diagnostic yield in the workup of patients with obscure small-bowel bleeding. Strictly defined positive findings are associated with a favorable outcome.     

Cutaneous ulcers: An unusual manifestation of inherited thrombophilia

We report two cases with cutaneous lesions found to be associated with factor V Leiden mutation and low S protein levels. At the time of presentation, no other symptoms were reported. Histopathology of both lesions revealed the presence of widespread intravascular thrombi. The therapeutic response to oral anticoagulants in the first case was dramatic, leading to complete healing of the lesions. Inherited causes of thrombophilia manifested as cutaneous lesions, although rare, should be considered in the differential diagnosis of occlusive vasculopathy.     

Minimally invasive parathyroidectomy in patients with previous endocrine surgery

Objective:

Previous endocrine neck surgery (PENS) in patients with sporadic primary hyperparathyroidism (PHP) is considered a contraindication for minimally invasive parathyroidectomy (MIP). The purpose of our study was to determine the effectiveness of MIP in such patients.

Methods:

From January 2004 to December 2009, 270 patients with PHP were treated in our department; 30 had had PENS in the past. Eighteen were selected to have MIP, while the other 12 had traditional neck explorations. Selection criteria for MIP were unilateral single- or double-gland disease localized preoperatively with at least 2 concordant imaging techniques and patient informed consent. Imaging studies included high-resolution neck ultrasound and sestamibi scan in most patients, and CT scan, selective venous sampling, and MRI in 7 patients. Unilateral explorations via a lateral approach with the patients under local (UALA in 13 patients), general (MIP in 4 patients), or local followed by general anesthesia (1 patient) were performed.

Results:

Sixteen of the 17 patients became normocalcemic after the operation. There was no conversion to traditional exploration. A single adenoma was found in 16 patients and hyperplasia in one. One patient underwent a successful parathyroidectomy 8 months later via mesothoracoscopy, because the parathyroid gland was localized correctly but was beyond access via neck. There were no postoperative complications. Mean duration of the procedure and length of stay were similar to MIP in patients without PENS. Mean follow-up of 33 months (range, 4 to 70) did not reveal any recurrence.

Conclusion:

These results illustrate that MIP is a valuable option in select patients with sporadic PHP and PENS. Localization with 2 or more concordant imaging techniques could avoid intraoperative sestamibi or qPTH testing with low morbidity (0%), high biochemical cure rate (100% in this series), rapid recovery, and finally substantially lower the cost of the procedure.     

Pharmacological treatment of hyperthyroidism during lactation: review of the literature and novel data

Antithyroid drugs (ATD) are used as a first line treatment in thyrotoxicosis. Propylthiouracil (PTU), carbimazole (CMZ) and methimazole (MMI) are available. During absorption CMZ is bioactivated to MMI. Initially, mothers were not allowed to breastfeed during treatment with ATD. Newer studies minimized the risk for mother and infant. PTU should be preferred over MMI due to its lower milk concentration. Recent studies have shown severe hepatic dysfunction for both ATD, but especially for PTU, in hyperthyroid patients. Most of those cases were idiosyncratic, not-dose related and presented a latent period of occurrence. No biomarkers could predict hepatic damage. The American Thyroid Association (ATA) has recommended that PTU should not be prescribed as the first line agent in children and adolescents. Its use might be accepted in the first trimester of pregnancy for severe thyrotoxicosis or for patients with previous MMI adverse reactions. Considering the potential harmful effects of PTU, MMI should be used instead during lactation.