Large foreign body reaction to tension-free vaginal tape masquerading as inguinal hernia.

We report a case of a 73-year-old woman who presented to general surgery with a tender lump in the groin 5 years after insertion of a tension-free vaginal tape. The lesion was thought to be an incarcerated inguinal hernia. Emergency surgical exploration revealed a 7 × 5 × 4 cm soft tissue mass which was adherent to the external inguinal ring, emanating from the end of the tension-free vaginal tape at the level of the symphysis pubis. Resection and histological examination revealed a central track of granulation tissue with a surrounding foreign body inflammatory response. The surgery was complicated by an infected seroma requiring surgical drainage and antibiotic therapy, following which the patient made a full recovery. Large foreign body reaction is a rare but an important complication of tension-free vaginal tapes and may be mistaken for a groin hernia or lymphadenopathy.

Heterotopic abdominal pregnancy with persistent trophoblastic tissue.

Heterotopic pregnancy is a well-established complication of assisted reproductive technology. We report a case of intrauterine pregnancy combined with abdominal pregnancy diagnosed at 12 weeks in a 37-year-old nulliparous woman. Following surgical resection of the ectopic, implantation of hemorrhagic ectopic trophoblastic tissue onto bowel serosa, mesentery and omentum persisted. Due to the high risk of additional bleeding, systemic methotrexate was administered to the patient. The intrauterine pregnancy progressed well and a live infant was born at 27(+3) weeks. In such difficult cases, systemic methotrexate appears to have therapeutically helpful effects at low dosing regimens without immediate fetal toxicity.

Experience of methadone therapy in 100 consecutive chronic pain patients in a multidisciplinary pain center.

OBJECTIVE: The objective of the study was to describe the experience of methadone use in 100 consecutive chronic pain patients managed in a single multidisciplinary center. DESIGN: A chart review of chronic pain patients on methadone therapy initiated at the Wasser Pain Management Center from January 2001 to June 2004. SETTING, PATIENTS, AND INTERVENTION: Outpatients receiving methadone for chronic pain management in a tertiary multidisciplinary pain center. OUTCOME MEASURE: Effects on pain relief and function, conversion ratio from other opioids, side effects, and disposition were reviewed. RESULTS: Charts of 100 methadone patients (age 45 +/- 11 years old; M/F: 3/7; duration of pain 129 +/- 110 months) managed by five physicians and one nurse were reviewed. The main reason for the initiation of methadone therapy was opioid rotation (72%). The average oral morphine equivalent dose was 77 mg/day before methadone therapy, and the methadone dose after initial stabilization was 42 mg with no consistent conversion ratio observed. The mean duration of methadone therapy was 11 months. Most of the patients (91%) were taking concomitant adjuvant analgesics or psychotropic agents, mostly antidepressants and anticonvulsants. The average Numeric Verbal Rating Score before and after methadone treatment was 7.2 +/- 1.7 and 5.2 +/- 2.5 (P < 0.0001). Thirty-five patients discontinued their methadone treatment mainly because of side effects, ineffectiveness, or both. CONCLUSION: From our experience, methadone is an effective alternative to conventional opioids for chronic pain management when used by experienced clinicians in a setting that allows for close monitoring and careful dose initiation and adjustment.

Involuntary Treatment of Patients With Life-Threatening Anorexia Nervosa.

Anorexia nervosa has the highest mortality rate of any psychiatric illness. Predictors of mortality include chronicity of the illness, critically low body weight, and binging and purging behavior. Delusional beliefs body image, coupled with impaired judgment and cognition caused by starvation, often result in these patients adamantly resisting efforts to treat them. Guardianship, although useful in assisting with medical treatment decisions for patients with anorexia nervosa who are critically medically ill, is usually an inadequate intervention with respect to psychiatric treatment for these patients. Despite the severity and risk of the illness, there is often reluctance among providers to initiate involuntary treatment for patients with anorexia nervosa. Recent legal cases involving patients with anorexia nervosa have addressed the role of the committing court in authorizing treatment decisions and, in one case, opining that a patient was best served by receiving treatment in another state. Other related concerns addressed by the courts include ensuring that appropriate criteria are used for hospital admission, clarifying that the definition of grave disability as it pertains to anorexia does not require that the patient be close to death and that medications are often warranted in treating patients with the disease.

Use of telemedicine in chronic pain consultation: a pilot study.

OBJECTIVES: Telemedicine has been used extensively in various settings, including monitoring patient treatment response and counseling. However, there are few data on the application of telemedicine to chronic pain patients. The present study was the first pilot project to determine whether telemedicine technology for chronic pain consultation was feasible, cost-saving, and satisfactory to patients and pain physicians. METHODS: A prospective pilot study was conducted on chronic pain patients requiring follow-up consultations using telemedicine technology. Patients were interviewed by phone following the consultation. RESULTS: Eleven telemedicine anesthesia consultations involving eight patients (age 42+/-9 years; six men, two women) were performed. All were follow-up consultations. The average distance from patients' home to the clinic was 314+/-170 km. The reasons for consultation were for update of patient progress (10/11), medication change (6/11), and counseling (3/11). The time to complete the consultation was 24.5+/-9.5 minutes. The data for the time and the cost that the patient spent on the consultation are presented as median and 25% to 75% interquartile range. Patients having telemedicine consultations spent 0.9 hours (0.83-1) and Canadian dollar 3 (dollar 2-4) versus an estimate of 8 hours (6-8) and Canadian dollar 80 (dollar 46-260) for a conventional consultation (both P<0.005). Telemedicine consultation was found to be highly satisfactory to the patient and the consulting and attending anesthesiologists. CONCLUSIONS: This pilot study indicates that telemedicine follow-up consultations for chronic pain patients are feasible and cost-saving. Patients and anesthesiologists were highly satisfied with telemedicine consultation. Patients reported a significant saving in time and cost compared with a conventional consultation.

Oral versus vaginal misoprostol administered one hour before surgical termination of pregnancy: a randomised controlled trial.

OBJECTIVE: To assess the efficacy of oral and vaginal misoprostol as cervical priming agents administered 1 hour before first trimester surgical termination of pregnancy. DESIGN: A randomised controlled trial. SETTING: Chelsea and Westminster Hospital, London. POPULATION: Pregnant women of 10 weeks or less gestation attending the termination of pregnancy clinic. METHODS: Ninety eligible women were recruited to the study during September 2001 and September 2002. Women were randomised to one of the three groups: misoprostol administered orally (400 microg), misoprostol administered vaginally (800 microg) and standard care (no cervical priming agent) administered prior to surgical termination of pregnancy. Under general anaesthesia, and prior to the operation, a cervical tonometer was used to determine the main outcome measures. MAIN OUTCOME MEASURES: Baseline cervical dilatation and the cumulative force required to dilate the cervix from 3 to 9 mm. RESULTS: There was no significant difference in the mean baseline cervical dilation (P= 0.16) or the cumulative force required to dilate the cervix (P= 0.12) between the three randomised groups. CONCLUSION: No cervical priming effects were detectable with oral or vaginal misoprostol administered 1 hour before first trimester surgical termination of pregnancy.