Uterine myomata and outcome of assisted reproduction

The aim of this work was to study the effect of uterine myomata on the implantation rate and outcome in in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). Among 406 patients, 51 (12.6%) were found to have uterine corporeal myomata. Twelve patients were excluded from the study as they had large myomata, submucous myomata or intramural myomata encroaching on the cavity. These patients were advised to have myomectomy before being enrolled in the IVF/ICSI programme. The remaining patients (n = 39) were sorted according to the number, site and size of the myomata as assessed by transvaginal sonography. Three patients had more than one myoma. Most of the myomata were subserous (72.7%) and the mean diameter of the myomata was 3.5 +/- 0.9 cm. A control group (n = 367) was chosen with normal uteri and no history of uterine reconstruction surgery. The mean age of myoma patients was 34.7 +/- 3.6 years as compared to 34.0 +/- 4.4 years in the control group. The age, period of infertility, body mass index, duration and number of human menopausal gonadotrophin ampoules needed for stimulation, oestradiol levels, number of oocytes retrieved and the fertilization rate were not significantly different in the myoma patients compared to the control group. Fifteen myoma patients (38.5%) subsequently showed one or more pregnancy sacs on ultrasonography of which three (20%) spontaneously aborted during the first trimester and two (13.3%) had preterm labour, as compared to 123 (33.5%), 19 (15.5%) and nine (7.3%) respectively, among the control group (P = 0.27, 0.33 and 0.21). In conclusion, uterine corporeal myomata, not encroaching on the cavity and <7 cm in mean diameter, do not affect the implantation or miscarriage rates in IVF or ICSI.      

四氯偶氮苯在大鼠胆汁中的分泌和代谢

四氯偶氮苯（３,３’,４,４’ｔｅｔｒａｃｈｌｏｒｏａｚｏｂｅｎｚｅｎｅ,ＴＣＡＢ）和四氯氧化偶氮苯（３,３’,４,４’ｔｅｔｒａｃｈｌｏｒｏａｚｏｘｙｂｅｎｚｅｎｅ,ＴＣＡＯＢ）是在合成氯代或二氯代苯胺类除草剂时生成的污染废弃物。此类除草剂经...     

Assessment of thyroidal "C" cell secretion in osteoporotic girls with Turner''s syndrome. Basal and calcium-stimulated levels of total calcitonin, extractable calcitonin and katakalcin

Osteoporosis is a common finding in Turner's syndrome. To test the hypothesis that calcitonin deficiency may contribute to bone mineral loss in Turner's syndrome, we studied basal and calcium-stimulated (2 mg/kg body weight in 5 min) levels of total calcitonin, extractable calcitonin and katacalcin in 15 girls with Turner's syndrome and osteoporosis. Fifteen age-matched healthy girls were studied as controls. Both basal calcitonin (total and extractable) and katacalcin values were not significantly different in patients with Turner's syndrome in comparison with those of the controls. The calcium stimulation test showed a similar "C" cell secretory reserve in both groups. The calculation of delta CT/delta iCa of total and extractable calcitonin and delta KC/delta iCa, which accounts for individual variations in serum ionized calcium increases, did not show any significant difference between girls with Turner's syndrome and controls. We conclude that calcitonin deficiency is not a causative factor of osteoporosis in girls with Turner's syndrome and that in this syndrome long-life estrogen deficiency does not impair "C" cell secretory activity.     

Elective day-case laparoscopic cholecystectomy: a formal assessment of the need for outpatient follow-up

Introduction

Elective laparoscopic cholecystectomy (LC) is performed routinely as day-case surgery. Most hospital trusts have a policy of no routine postoperative outpatient follow-up although there are no formal guidelines on this. The aim of this retrospective study was to identify the incidence of complications, the degree of symptom resolution and patient satisfaction with a view to formally appraising the need for outpatient follow-up.

Methods

Patients who underwent LC in the period between February 2011 and June 2012 were contacted retrospectively by telephone. A standardised questionnaire was used to ascertain the incidence of surgical site infection (SSI), other complications, symptom resolution and patient satisfaction.

Results

A total of 211 responses were collected. The rate of SSI was 7.6% (n=16), with the only specific risk factor being smoking (p=0.027). All other complications had a combined incidence of 7% (n=15). There was complete resolution of symptoms in 64% of patients. Of the 36% of patients with residual symptoms, 45% described abdominal discomfort or pain, 41% described reflux symptoms and 14% complained of diarrhoea. Patient satisfaction was very high (96%), yet 33% of patients visited their general practitioner postoperatively in relation to their surgery.

Conclusions

Patients are highly satisfied with elective day-case LC. However, SSI is not uncommon, occurring in 1 in 13 patients. Although the majority of patients experience complete symptom resolution, a significant proportion do not. In our experience, routine outpatient follow-up is not required. Nevertheless, the lack of formal follow-up may prove a missed learning opportunity, potentially resulting in inappropriate patient selection for surgery.     

Quality of life outcome of critical care survivors eighteen months after discharge from intensive care

Aim

To assess the changes in health-related quality of life in patients discharged from the intensive care unit (ICU).

Methods

At the General University ICU, Trauma Hospital in Athens, 242 patients were enrolled prospectively over a study period of 18 months. Out of these, 116 participants (47.9%) completed all survey components at 6, 12, and 18 months. We used Quality of Life-Spanish (QOL-SP) to assess the health-related quality of life. Patients or their relatives were interviewed on ICU admission and at 6, 12, and 18 months after discharge from the ICU.

Results

Mean quality of life score of the patients increased from 2.9 ± 4.8 (out of maximum 25 points) on ICU admission to 7.0 ± 7.2 points at 6 months after discharge, and then decreased to 5.6 ± 6.9 points at 18 months (P<0.001; Friedman test). Multilinear regression analysis showed that the variables which had the strongest association with the quality of life on admission were age (P = 0.002) and male sex (P = 0.001), whereas age (P<0.001), length of ICU stay (P<0.001), and male sex (P = 0.002) had the strongest association 18 months after discharge from the ICU. Survival rate was 66.9% at discharge from ICU and 61.6% at hospital discharge. There were 33% deaths in the ICU, 5.3% in the hospital, and 6.2% after ICU discharge. There were 7.4% patients lost to follow-up.

Conclusions

After discharge from the ICU, patients’ quality of life was poor and showed an improvement at 18 months after discharge, but was still worse than on admission. Age, ICU length of stay, and male sex were the factors that had the strongest impact on the quality of life on admission and at 18 months after discharge from the ICU.The cost of intensive care and limited resources directed to patients with a poor prognosis raise questions about the utilization of such resources. Since the need for intensive care in several countries exceeds its availability (1), intensive care specialists are forced to admit those patients who will benefit most. There is an increasing pressure that the assessment of long-term survival and quality of life of survivors should be incorporated into outcome evaluation of intensive care unit (ICU) (2).Instruments for assessing quality of life in critically ill patients surviving intensive care include EuroQol-5D (EQ-5D), Nottingham Health Profile (NHP), Sickness Impact Profile (SIP), Medical Outcomes Study 36-item Short Form (SF-36), and Quality Of Life-Spanish (QOL-SP) (3). These instruments aim to evaluate the aspects of health important for all patients. Several cross-sectional studies have used generic, multidimensional quality of life instruments to compare health-related quality of life of intensive care patients with the that of the general population and found a considerable deterioration in the former group (3,4). However, such evidence may be misleading if pre-hospitalization health-related quality of life is not taken into account.Quality of life is an important endpoint in assessing long-term results of intensive care, but the ideal timing for such an assessment is still unclear. This topic has been covered in some reports dealing with pre-ICU assessment of health-related quality of life (3). QOL-SP questionnaire, developed by Fernandez et al (5), is specifically designed for critically ill patients. This is one of the few instruments that have been validated in a critical care population, but it is neither widely used nor well known in the critical care community. A few studies have used QOL-SP to assess medical (6), surgical (7), or multiple trauma patients (8), and to measure the quality of life before ICU, as well as the changes in quality of life from baseline to 6 and 24 months.Despite its limitations, we used this instrument to assess the changes in health-related quality of life in people who survived critical illness in a Greek medical-surgical ICU at 6, 12, and 18 months after ICU discharge, and to compare these data with their pre-admission status.     

Priapism following continuous thoracic epidural anaesthesia: emergency or a benign condition?

Priapism is a rare complication of epidural anaesthesia, and the pathophysiology is poorly understood. In general, 95% of all priapism episodes is ischemic because of decreased penile blood flow, and therefore requires immediate treatment. A case is reported of a 45‐year‐old male patient in which a clear relation is demonstrated between continuous thoracic epidural analgesia and priapism after transabdominal nephrectomy. The level of epidural anaesthesia supports the theory that the erection is a consequence of increased penile blood flow, thus a relatively harmless condition. However, confirmation by serial cavernous blood gas analysis or colour duplex ultrasonography is mandatory. Until this hypothesis is confirmed, termination of epidural infusion is advised as a primary treatment.     

Bupivacaine-induced myocardial depression and pulmonary edema: a case report

Central nervous system and cardiovascular toxicity are well-known side effects of bupivacaine. We report a case of bupivacaine-induced myocardial depression and cardiogenic pulmonary edema. A previously healthy woman developed soon after bupivacaine epidural injection of 5 mL 0.5% (25 mg) cardiogenic shock complicated with pulmonary edema. There were pronounced rales on auscultation with a butterfly sign on chest radiograph. A cardiac ultrasound showed reduced myocardial contractility, diffuse hypokinesia, left ventricular ejection fraction (LVEF) 25%, mitral and pulmonary insufficiency. Right heart catheterization showed increased pulmonary artery wedge pressure (34 mm Hg) and a pulmonary artery pressure of 48 over 33 mm Hg. These findings suggest myocardial depression owing to bupivacaine sodium channel blocking of myocardial nerve and tissue and subsequent reduction of myocardial contractility. The patient completely recovered with normalization of clinical, roentenographic, ultrasound, and hemodynamic findings and discharged 10 days later in good condition.