Long-term results in the treatment of menorrhagia and hypermenorrhea with a thermal balloon endometrial ablation technique.

BACKGROUND AND OBJECTIVES: Evaluation of long-term results using a thermal balloon endometrial ablation technique to treat menorrhagia and hypermenorrhea, considered dysfunctional uterine bleedings. METHODS: A single-arm, prospective study with long-term follow-up of 48 months at the department of obstetrics and gynecology, University of Kiel, Germany. Following hysteroscopic evaluation of the uterine cavity and fractionated curettage, the Cavaterm endometrial thermal ablation technique was performed on 70 patients over the age of 40 with menorrhagia and hypermenorrhea in whom medical treatment had previously failed. The study included a group of 10 patients with adenomyosis and uterine fibroids. RESULTS: In 65 patients, a complete 48-month follow-up evaluation was possible: 58% of patients reported amenorrhea and 33% hypomenorrhea. Nine percent of patients remained eumenorrheic. Fifty percent of the small group with failed indications for the procedure had to undergo a hysterectomy. CONCLUSIONS: The Cavaterm thermal coagulation system in the earlier mode of application (15 minutes at a temperature of 70 degrees C and a pressure of 200 mm Hg) is a safe and highly effective method of endometrial ablation resulting in a minimal amount of posttreatment menstrual bleeding.     

Realität der operativen endoskopischen Chirurgie in der gynäkologischen Chirurgie

Zusammenfassung Das Spektrum der gyn?kologisch-operativen Endoskopie hat sich seit den Tagen von RaoulPalmer in Frankreich 1964 mit den gut 25-j?hrigen Aktivit?ten von KurtSemm zum h?ufigsten gyn?kologischen Eingriff überhaupt entwickelt. Am gesamten Genitale, am Uterus, den Tuben und an den Ovarien lassen sich fast alle benignen Ver?nderungen endoskopisch diagnostizieren und therapieren. Selbst die endoskopischee supracervikale Hysterektomie stellt heutzutage keine schwierige Operation mehr dar. Die atypisch lokalisierte Schwangerschaft kann pelviskopisch diagnostiziert und therapiert werden. Bei malignen Ver?nderungen raten wir derzeit von einer endoskopischen Therapie ab, da das Metastasierungsrisiko noch nicht ausdiskutiert ist. Die pelvine Lymphonodektomie ist endoskopisch leicht m?glich und die Chirurgen und Urologen gehen uns dabei bereits endoskopisch voran. Die „Minimal Invasive Chirurgie“ per endoskopiam ist keine Schlüssel-Loch-Chirurgie mehr, sondern wird auf dem Videoschirm bereits allen im Operationssaal anwesenden ?rzten und Schwestern zur Kritik und Verbesserung zug?nglich gemacht. Ein echtes Teamwork von Operateur, Assistent, Kameramann und Schwester führt zu einer für die Patientin bei Einhalten der Sicherheitsschritte befriedigenden und sicheren Operation. Das gesamte Spektrum der Operationen in der Gyn?kologie hat sich auch per laparotomiam in den letzten Jahren der Organerhaltung zugewandt. Eine kombinierte medikament?s-operative Therapie erlaubt jetzt selbst die Uteruserhaltung bei Myomen, die knapp s?uglingskopfgro? werden k?nnen. Grenzen zur endoskopischen Chirurgie setzt heute immer noch das Instrumentarium, obwohl dieses der modernen Zeit zunehmend angepa?ter von vielen Firmen weiter entwickelt wird. Beispiele dafür bietet der Serrated Edged Macro-Morcellator S.E.M.M. zur Entfernung von bis zu faustgro?en Myonen und verbesserte Nahttechniken. End-Zu-End-Anastomosen an den Tuben, die noch vor einigen Jahren Dom?nen der Mikrochirurgie waren, sind mit der gleichen Erfolgsrate pelviskopisch durchführbar. Ovarialtumoren werden unter zu Hilfenahme verschiedener Technologien (Laser, Koagulation etc.) aus ihrem Bett ausgesch?lt und aus der K?rperh?hle extrahiert. Die Ovarialnaht wird durch eine Endonaht oder durch Fibrinkleber adaptiert.     

Evaluation of filling materials in membrane‐protected bone defects. A comparative histomorphometric study in the mandible of miniature pigs.

In recent years, bone grafts and bone substitutes have been increasingly utilized underneath barrier membranes to optimize the treatment outcome of bone reconstructive therapy for defects in the alveolar process. In the present study, 4 different filling materials were evaluated in bone defects of similar dimensions in the mandible of miniature pigs. Blood clots and autografts were used as controls. The defects were covered with barrier membranes and allowed to heal for 4, 12 or 24 weeks. Histologic examination demonstrated that bone repair progressed through a programmed sequence of maturation steps closely resembling the pattern of bone development and growth regardless of whether bone grafts or substitutes were present or not. Histomorphometric analysis showed that autologous bone grafts (autografts) had the best osteoconductive properties during the initial healing period, with 39% of newly formed bone inside the membrane-covered defects at 4 weeks of healing. In addition, 87% of the graft surfaces were already covered by bone at this time. Both values were significantly higher for autografts than for the 4 alternative bone fillers (P < or = 0.05). At 12 weeks, these differences were no longer apparent, with all 5 filling materials showing similar values. Among the tested bone substitutes, tricalcium phosphate (TCP) showed a significantly higher percentage of bone fill at 24 weeks of healing. It can be concluded that sites filled with autografts clearly demonstrated the best results underneath barrier membranes in the early phase of healing. As far as degradation and substitution are concerned, TCP showed the most promising results. This filler, however, needs to be tested further in a more demanding animal model. Less favorable results were obtained for coral-derived hydroxyapatite granules and for demineralized freeze-dried bone allografts.     

A locus for spondylocarpotarsal synostosis syndrome at chromosome 3p14

Spondylocarpotarsal synostosis syndrome is a rare autosomal recessive disorder characterised by vertebral fusions, frequently manifesting as an unsegmented vertebral bar, as well as fusions of the carpal and tarsal bones.

In a study of three consanguineous families and one non-consanguineous family, linkage analysis was used to establish the chromosomal location of the disease gene. Linkage analysis localised the disease gene to chromosome 3p14. A maximum lod score of 6.49 (q = 0) was obtained for the marker at locus D3S3532 on chromosome 3p. Recombination mapping narrowed the linked region to the 5.7 cM genetic interval between the markers at loci D3S3724 and D3S1300. A common region of homozygosity was found between the markers at loci D3S3724 and D3S1300, defining a physical interval of approximately 4 million base pairs likely to contain the disease gene.

Identification of the gene responsible for this disorder will provide insight into the genes that play a role in the formation of the vertebral column and joints.

     

Power morcellation inside a secure endobag: a pilot study

Introduction: Unprotected power morcellation can lead to a spread of previously undiagnosed malignancy. We present a new containment bag with two closable trocar insertion sites to reduce this risk. This pilot study was designed to assess the feasibility of this device under everyday conditions.

Material and methods: The containment bag was used in ten laparoscopic supracervical hysterectomies. We evaluated time requirement for bag insertion into the abdominal cavity and in-bag morcellation. A 2000?ml polyurethane morcellation bag was used for all interventions. All surgeries were carried out in a three-trocar setting.

Results: We carried out ten supracervical hysterectomies. No intraoperative complications and no bag ruptures occurred. The meantime requirement to insert the bag and prepare the specimen for morcellation was 10.5?min (range, 7–19?min). The mean specimen weight was 191.9?g (range, 32–710?g). Mean morcellation time was 10.5?min (range, 3–28?min), mean weight of remaining tissue and fluid in the bag after morcellation was 12.1?g (range, 7–19?g).

Conclusions: The presented data demonstrate that the endobag can be successfully applied in the clinical routine. Further studies are required to evaluate additional characteristics, such as individual learning curve and time requirements.     

Effects of a dynamic progressive orthotic intervention for chronic hemiplegia: A case series

Study designCase series design on a single subgroup of participants.IntroductionManagement of hypertonicity and resistance to passive movement (RTPM) in the upper extremity is an intractable problem for persons with stroke and the therapists who provide their care. Therapists have limited options for assessment and treatment of this condition which can profoundly limit functional performance and quality of life.Purpose of the studyTo evaluate the effect of a 12-week dynamic progressive orthotic intervention in persons with chronic stroke exhibiting wrist flexion contracture who are residents of a long-term skilled nursing facility.MethodsA custom-fitted dynamic progressive wrist extension orthotic was applied to 6 residents with chronic stroke. The orthotic was worn for 4 h daily, 4×/week for 12 weeks. Wrist passive range of motion (PROM) and RTPM were measured weekly and after discontinuation of the orthotics using the Modified Ashworth Scale and the Tardieu Scale of Spasticity. Signal analysis of electromyographical (EMG) flexor response to extensor stretching was also measured before and after orthotic intervention using maximal root mean square (RMS) values and EMG burst onset time.ResultsA moderate effect was found for changes in PROM with the orthotic intervention. Progress made diminished following discontinuation. Moderate effects were also seen in EMG measures which indicated increases in amount of resistive-free movement following intervention.ConclusionA dynamic progressive orthotic intervention can be an effective option for increasing wrist PROM and reducing RTPM in persons with chronic stroke.Level of evidence4.     

Improving residents’ confidence in using psychosocial skills

OBJECTIVE: To evaluate an intensive training program’s effects on residents’ confidence in their ability in, anticipation of positive outcomes from, and personal commitment to psychosocial behaviors. DESIGN: Controlled randomized study. SETTING: A university- and community-based primary care residency training program. PARTICIPANTS: 26 first-year residents in internal medicine and family practice. INTERVENTION: The residents were randomly assigned to a control group or to one-month intensive training centered on psychosocial skills needed in primary care. MEASUREMENTS: Questionnaires measuring knowledge of psychosocial medicine, and self-confidence in, anticipation of positive outcomes from, and personal commitment to five skill areas: psychological sensitivity, emotional sensitivity, management of somatization, and directive and nondirective facilitation of patient communication. RESULTS: The trained residents expressed higher self-confidence in all five areas of psychosocial skill (p<0.03 for all tests), anticipated more positive outcomes for emotional sensitivity (p=0.05), managing somatization (p=0.03), and nondirectively facilitating patient communication (p=0.02), and were more strongly committed to being emotionally sensitive (p=0.055) and managing somatization (p=0.056), compared with the untrained residents. The trained residents also evidenced more knowledge of psychosocial medicine than did the untrained residents (p<0.001). CONCLUSIONS: Intensive psychosocial training improves residents’ self-confidence in their ability regarding key psychosocial behaviors and increases their knowledge of psychosocial medicine. Training also increases anticipation of positive outcomes from and personal commitment to some, but not all, psychosocial skills. Presented at the annual meeting of the Society of General Internal Medicine, Washington, DC, April 27–29, 1994. Supported by the Fetzer Institute in Kalamazoo, MI.     

Expanding the donor pool: regional variation in pediatric organ donation rates

There are limited published data on pediatric organ donation rates. The aim of this study was to describe the trends in pediatric organ donation over time and to assess the regional variation in pediatric deceased organ donation. OPTN data were utilized to assess the trends in pediatric organ donation over time. The number of deceased pediatric organ donors was indexed using regional mortality data obtained from the National Center for Health Statistics and compared across UNOS regions and two different eras. The number of pediatric deceased organ donors has declined in the recent era, largely driven by fewer adolescent donors. For all age groups, there is significant regional variation in organ donation rates, with identifiable high‐ and low‐performing regions. Expansion of the donor pool may be possible by optimizing organ donation in regions demonstrating lower recruitment of pediatric donors. Using the region with the highest donation rate for each age group as the gold standard, we estimate a potential 24% increase in the number of donors if all regions performed comparably, equating to 215 new pediatric donors annually.