Natural history of sonographically detected simple unilocular adnexal cysts in asymptomatic postmenopausal women

OBJECTIVE: To determine the natural history of simple unilocular adnexal cysts in asymptomatic postmenopausal women. METHODS: Eight thousand seven hundred ninety-four asymptomatic postmenopausal women underwent transvaginal ultrasound as part of routine gynecological check-up at our institution between January 1995 and June 2002. All patients in whom a simple unilocular adnexal cyst was found out were offered surgical treatment or conservative follow-up with serial transvaginal ultrasound at 6-month intervals. In all these cases, serum CA-125 levels was determined. RESULTS: Two hundred twenty-three simple adnexal cysts in 215 women were found out (prevalence: 2.5%). Annual incidence did not change significantly. Sixty-six (30.6%) women were lost after initial diagnosis. One hundred and forty-nine patients with 153 cysts were entered ultimately in the study. Forty-five (30%) underwent surgery (34 after initial diagnosis and 11 during follow-up). A total of 49 cysts were removed. The most frequent histological diagnosis was serous cystadenoma (84%). There was a case of a stage IA ovarian carcinoma (2% of the cysts removed, 0.6% of all the cysts included in the study). One hundred and four patients with 104 cysts underwent conservative follow-up throughout the study period. Forty-six (44%) of these cysts resolved spontaneously (74% of them within 2 years). In 14 (30%) of these women, a new cyst was diagnosed when follow-up went on. In 58 patients, cysts persisted during all study period (median follow-up: 48 months, range: 6-90 months), 69.6% of them remained unchanged, 17.2% increased, and 17.2% decreased. Patients in whom cysts resolved spontaneously had a shorter menopausal time (P=0.001) and tend to be younger (P=0.06). No differences were found regarding cysts' features. CONCLUSION: The risk of malignancy of simple adnexal cysts in asymptomatic postmenopausal women is low. Almost half of them will resolve spontaneously during follow-up. Most of those that persist remain unchanged. Asymptomatic postmenopausal women having simple adnexal cysts can be managed conservatively with a very reasonable degree of reassurance.     

Cyclooxygenase-2 expression in borderline ovarian tumors

OBJECTIVES: The aim of the study was to investigate by immunohistochemistry the expression of cyclooxygenase-2 (COX-2) in a single institutional series of borderline ovarian tumors (BOT). Moreover, to perform a comparative analysis, COX-2 expression was also analyzed in benign and malignant ovarian tumors. METHODS: Paraffin-embedded sections form 51 BOT, 26 benign, and 37 malignant ovarian tumors were incubated with polyclonal antiserum against COX-2. The results were calculated as the product of the percentage of the immunostained tumor cells by the relative staining score. Cases with immunostaining values of >1 were considered COX-2-positive. RESULTS: Thirty-four (66.7%) of fifty-one BOT were considered as COX-2-positive, and this rate was not significantly different with respect to COX-2 positivity in benign (50.0%) and in malignant (51.3%) ovarian tumors (P value = 0.23). A significantly higher percentage of COX-2 positivity was found in serous (24 of 24, 100%) with respect to mucinous (9 of 26, 34.6%) BOT (P value = 0.0001). Moreover, 7 (63.6%) of 11 endocervical-type mucinous borderline ovarian tumors were COX-2-positive with respect to only 2 of 15 (13.3%) intestinal-type mucinous BOT (P value = 0.013). The same trend was observed in benign lesions, with COX-2 positivity in 9 of 11 (81.8%) of serous versus 4 of 15 (26.7%) of mucinous tumors (P value = 0.015). On the other hand, no difference was found in the percentage of COX-2 positivity in serous (14 of 29, 48.3%) versus mucinous (5 of 8, 62.5%) ovarian carcinomas (P value = 0.22). CONCLUSIONS: COX-2 is differently expressed in BOT according to different histotype. Moreover, an increase of COX-2 positivity was observed from mucinous intestinal BOT to frankly malignant ovarian tumors suggesting that COX-2 overexpression might be involved in mucinous ovarian carcinogenesis.     

Acute respiratory distress syndrome, the critical care paradigm: what we learned and what we forgot

In the last several years, we definitely learned that the acute respiratory distress syndrome lung is small, nonhomogeneous, and that mechanical ventilation in this baby lung may cause physical damage as well as inflammatory reaction. The clinical benefit of the gentle lung treatment, based on a decrease of global/regional stress and strain into the lung, has been finally proved. However, we forgot the importance of lung perfusion and its distribution in this syndrome and, besides a low tidal volume, we still do not know how to handle the other variables of mechanical ventilation. Measurements of variables as transpulmonary pressure and end expiratory lung volume, for a rational setting of mechanical ventilation, should be introduced in routine clinical practice.     

Bench-to-bedside review: Chest wall elastance in acute lung injury/acute respiratory distress syndrome patients

The importance of chest wall elastance in characterizing acute lung injury/acute respiratory distress syndrome patients and in setting mechanical ventilation is increasingly recognized. Nearly 30% of patients admitted to a general intensive care unit have an abnormal high intra-abdominal pressure (due to ascites, bowel edema, ileus), which leads to an increase in the chest wall elastance. At a given applied airway pressure, the pleural pressure increases according to (in the static condition) the equation: pleural pressure = airway pressure × (chest wall elastance/total respiratory system elastance). Consequently, for a given applied pressure, the increase in pleural pressure implies a decrease in transpulmonary pressure (airway pressure – pleural pressure), which is the distending force of the lung, implies a decrease of the strain and of ventilator-induced lung injury, implies the need to use a higher airway pressure during the recruitment maneuvers to reach a sufficient transpulmonary opening pressure, implies hemodynamic risk due to the reductions in venous return and heart size, and implies a possible increase of lung edema, partially due to the reduced edema clearance. It is always important in the most critically ill patients to assess the intra-abdominal pressure and the chest wall elastance.     

Suprarenal fixation of endograft in abdominal aortic aneurysm treatment: focus on renal function

OBJECTIVE: The objective of this work was to evaluate any variation of renal function detected by renal scintigraphy after the suprarenal fixation of endografts for abdominal aortic aneurysm (AAA) repair. SUMMARY BACKGROUND DATA: In the few articles that have considered this problem, renal function was evaluated only by biochemical tests, which are inadequate in demonstrating small changes in renal function and in appreciating the worsening of a single kidney's function. METHODS: Between April 1999 and May 2002, 47 patients with an inappropriate infrarenal proximal neck had a suprarenal fixation for AAA. To assess renal function, a technetium-99m diethylene triamine penta-acetic acid (TC-DTPA) perfusion scintigraphy was performed preoperatively on the third postoperative day and at 6, 12 months, and then yearly thereafter. Worsening of renal function was defined as a decrease of glomerular filtration rate (GFR) > or =20% (detected with Gates method). Serum creatinine level was tested preoperatively and at the first and third postoperative day. RESULTS: Endograft deployment was technically successful in 44 patients (93.6%); clinical perioperative success was obtained in 46 patients (97.8%). In 12 patients (25.5%), a permanent reduction of the GFR was observed using postoperative TC-DTPA perfusion scintigraphy. By 99m TC-DTPA perfusion scintigraphy, a permanent reduction of GFR was observed postoperatively in 12 patients. A slight GFR reduction (<20%) was present in 7 (14.9%) patients, due to the planned occlusion of accessory renal arteries. A more significant GFR reduction (>20%) was present unexpectedly in 5 (10.6%) patients, in 3 of these a single kidney was involved, in 5 both with an increase of the serum creatinine level >20%. CONCLUSIONS: Suprarenal fixation of endografts in AAA treatment is a safe procedure with good early and midterm procedural results and a risk of GFR impairment (>20%) of 10.6%.     

Bilateral brachial plexus block

Bilateral regional anesthesia techniques in general and bilateral brachial plexus blocks in particular are rarely performed because they have few clinical indications. We present the case of a patient who presented to the operating room for bilateral upper extremity procedures where we thought regional anesthesia was appropriate. The anesthesia management is discussed as well as potential problems and complications. IMPLICATIONS: Reports on bilateral regional blocks are extremely rare in the literature. Whereas they have the potential for more complications than a single technique, they can be very useful in specific clinical situations.     

Epidural ropivacaine versus epidural morphine and the catabolic response to colonic surgery: stable isotope kinetic studies in the fasted state and during infusion of glucose

BACKGROUND: The authors examined the hypothesis that epidural administration of local anesthetic, in contrast to epidural analgesia with morphine, inhibits postoperative protein oxidation during administration of glucose. METHODS: Fourteen patients were randomly assigned to undergo a 6-h stable isotope infusion study (3 h fasted, 3 h feeding with 4 mg.kg(-1).min(-1) glucose) on the second day after colorectal surgery using epidural analgesia with either continuous ropivacaine or intermittent morphine. Protein synthesis, breakdown and oxidation, and glucose production were measured by L-[L-13C]leucine and [6,6-2H2]glucose. Substrate oxidation rates were determined by indirect calorimetry. Plasma concentrations of metabolic substrates and hormones were also measured. RESULTS: Whole body protein breakdown, oxidation, synthesis, and glucose production in the fasted state were similar between the two groups. Glucose administration decreased protein breakdown (P = 0.01), protein synthesis (P = 0.001), and glucose production (P = 0.001) to the same extent in both groups, whereas protein oxidation was not significantly affected. The type of epidural analgesia did not significantly influence the circulating concentrations of metabolic substrates and hormones in the fasted or in the fed state. Carbohydrate oxidation rate in the ropivacaine group was greater than in patients receiving morphine (P = 0.04), regardless of whether glucose was infused. CONCLUSION: Epidural analgesia achieved with ropivacaine or morphine does not suppress the catabolic response to surgery, either under fasting conditions or in the presence of an energy supply.