A Case of Painful Growing Abdominal Wall Mass during Pregnancy Requiring Resection in the Second Trimester.

Desmoid fibromatosis (DF) is a rare and locally aggressive neoplasm. We present a case of a 28-year-old previously healthy multigravida who noticed a lump in her abdomen near the umbilicus two months before becoming pregnant. It underwent rapid growth during pregnancy, causing pain and discomfort. Targeted ultrasound of the area showed an irregular mass measuring 0.9 × 1.7 × 1.4 cm. The origin of the mass was unclear, suggesting a connection with the intra-abdominal contents. An MRI done three weeks later revealed a subcutaneous ovoid mass measuring 3.0 × 2.3 × 3.0 cm, which was significantly larger. Due to pain and rapid growth, surgical resection was done at 25 weeks of pregnancy. Histopathological examination revealed a desmoid tumor. The patient had an uneventful recovery and term vaginal delivery without complications. Hence, our case serves as evidence that DF tumors can be surgically managed during pregnancy with minimal to no complications.

Anatomy and development of the pectoral fin vascular network in the zebrafish.

The pectoral fins of teleost fish are analogous structures to human forelimbs, and the developmental mechanisms directing their initial growth and patterning are conserved between fish and tetrapods. The forelimb vasculature is crucial for limb function, and it appears to play important roles during development by promoting development of other limb structures, but the steps leading to its formation are poorly understood. In this study, we use high-resolution imaging to document the stepwise assembly of the zebrafish pectoral fin vasculature. We show that fin vascular network formation is a stereotyped, choreographed process that begins with the growth of an initial vascular loop around the pectoral fin. This loop connects to the dorsal aorta to initiate pectoral vascular circulation. Pectoral fin vascular development continues with concurrent formation of three elaborate vascular plexuses, one in the distal fin that develops into the fin-ray vasculature and two near the base of the fin in association with the developing fin musculature. Our findings detail a complex, yet highly choreographed, series of steps involved in the development of a complete, functional, organ-specific vascular network.

Trichomonas vaginalis is most frequently detected in women at the age of peri-/premenopause: an unusual pattern for a sexually transmitted pathogen.

BACKGROUND: Trichomonas vaginalis is the most common nonviral sexually transmitted infection. However, because it is not a reportable disease in the United States, there is limited information on the age of infected individuals and their geographic distribution. OBJECTIVE: The purpose of this study was to evaluate the detection rates of T vaginalis infection compared with Chlamydia trachomatis by age and state in a commercial laboratory setting. STUDY DESIGN: Quantitative real-time polymerase chain reactions were used to detect the presence of T vaginalis and C trachomatis in cervicovaginal samples that were obtained during gynecologic examinations. A total of 1,554,966 and 1,999,077 samples from females 10-79 years old were analyzed retrospectively for the presence of T vaginalis and C trachomatis, respectively. RESULTS: The highest detection rate of an infection with T vaginalis was ages 47-53 years. For C trachomatis, the highest detection rate was ages 14-20 years. T vaginalis detection rate distribution by age shows a bimodal pattern with first peak at ages 21-22 years (4.0-4.1%) and a higher second peak at ages 48-51 years (5.4-5.8%). C trachomatis prevalence distribution by age shows a maximum peak of 8.6% at age 17 years and a rapid decline thereafter. In general, the detection rates of both pathogens were higher in the southeast and in states along the Mississippi River Valley than in other parts of the country. A nucleotide polymorphism associated with T vaginalis metronidazole resistance (ntr6TVK80STOP) was not associated with age and was found most frequently in specimens from New Mexico and Vermont. CONCLUSIONS: The detection rate of T vaginalis does not appear to decrease with age as observed for C trachomatis and reaches maximum rates in women 48-51 years old. The geographic distribution of T vaginalis appears to be broadly similar to that of other sexually transmitted diseases. The ntr6TVK80STOP polymorphism did not have a specific association with age or geography.

Colonoscopic tattoo dye spillage mimics endometriosis on laparoscopy.

Rare adverse effects of India ink injection spillage during colonoscopy have been reported. We present a case report in which prior colonoscopic India ink tattooing was found to mimic intraperitoneal endometriosis in a 48 year-old woman undergoing laparoscopic sterilization. Multiple black lesions suspicious for endometriosis involving the anterior and posterior cul-de-sac, left ovary, and omentum were found. A pathological assessment showed peritoneal tissue with focal dark pigment associated with mild chronic inflammation and deposition of tattoo pigment; there was no evidence of endometriosis in the specimens. Surgical recognition of tattoo ink spillage in the peritoneum is very important to prevent misinterpretation of peritoneal findings.

Detection rates of trichomonas vaginalis, in different age groups, using real-time polymerase chain reaction.

OBJECTIVE: The study aimed to compare the overall detection rate of Trichomonas vaginalis to Chlamydia trachomatis and Neiserria gonorrhea and report detection rates by age groups. MATERIALS AND METHODS: Real-time polymerase chain reaction was used to detect the presence of T. vaginalis, C. trachomatis, and N. gonorrhea in cervical samples obtained from patients during gynecological examinations. A total of 78,428, 119,451, and 117,494 samples from women age 12 to 75 years were retrospectively analyzed for the presence of T. vaginalis, C. trachomatis, and N. gonorrhea, respectively. T. vaginalis and C. trachomatis detection rates in Florida, New Jersey, and Texas were calculated in different age groups. RESULTS: The overall detection rate was 4.3% for T. vaginalis, 3.8% for C. trachomatis, and 0.6% for N. gonorrhea. The overall detection rate of T. vaginalis in Florida was 4.7% (n = 22,504), in New Jersey was 3.6% (n = 22,249), and in Texas was 4.5% (n = 33,675). Calculation of infection rates with T. vaginalis revealed differences between selected age groups with the highest detection rates in all 3 states found in age group 46 to 55 years (6.2%), which was higher than the overall detection rates in other age groups (p < .05 for all states). For C. trachomatis, the highest detection rate was found in age group 12 to 25 years (7.3%). CONCLUSIONS: The overall infection rates of T. vaginalis were higher compared with those of C. trachomatis and N. gonorrhea. Detection rates of T. vaginalis were found to be highest among women age 46 to 55 years and may be due to T. vaginalis infiltrating the subepithelial glands and being detected only during hormone-induced or antibiotic-induced changes in the vaginal flora.

Examination of genetic polymorphisms in newborns for signatures of sex-specific prenatal selection.

Success rate in human pregnancies is believed to be very low and sex-specific mechanisms may operate in prenatal loss. Assuming a sex-differential in prenatal loss exists, we examined genetic markers in biologically plausible targets in the HLA complex, other immune system-related and iron-regulatory genes in 388 healthy newborns from Wales (UK) using one sex as a control group for the other. Genotyping of 333 single nucleotide polymorphisms (SNPs) from 107 genes was achieved mainly by TaqMan assays. Twenty-two of autosomal SNPs showed frequency differences between 187 male and 201 female newborns either individually or as part of a haplotype. Of these, six markers (RXRB rs2076310, HLA complex haplotype HLA-DQA1 rs1142316-HLA-DRA rs7192-HSPA1B rs1061581, HIST1H1T rs198844, IFNG rs2069727, NKG2D rs10772266 and IRF4 heterozygosity) showed statistically robust differences between male and female newborns and multivariable modeling confirmed their independence. There were fewer males homozygote for combined wildtype genotypes of LIF rs929271, TP53 rs1042522 and MDM2 rs2279744 compared with females [OR = 0.3, 95% confidence interval (CI) = 0.1-0.8; P < 0.01] although these SNPs did not show any association individually. It is unlikely that SNPs have clinical utility as single markers in any trait with complex etiology but polygenic predictive models remain a possibility. If their validity is confirmed in larger studies of different populations and functional mechanisms of these preliminary associations are elucidated, these markers from the HLA complex, NKG2D region and cytokines may cumulatively have sufficient predictive value for susceptibility to prenatal selection in each sex.

[The physician and his poor patient--time for change].

Poverty and inequality will become increasingly part of the physician's realm of work. They have an impact on mortality, morbidity and on quality of life. Research has shown that physicians relate differently to poor patients, especially in relation to prescribing, but also in relation to referrals and during the consultation. They themselves are often unaware of this inclination. Physicians tend to relate to the poor in general terms, rather than to specific poor patients. Some physicians prefer not to treat poor patients at all. Physicians who come from a disadvantaged background and physicians who have had contact with the needy are predisposed to treat poor patients more often. Medical students who came in contact with poor populations, during or even before their studies, tended to relate more positively to poor persons after graduation. Medical schools that instituted special programs to educate towards lessening inequality succeeded in changing graduates' perceptions and behavior related to the poor. Solutions to lessen inequality in health include: a strong primary care sector, patient empowerment, corrective economic measures and the use of quality control and performance indicators as a means of reducing inequality. There is a need to increase awareness of the relevant components of the interaction between the physician with his poor patient and enhance the development of appropriate educational programs in medical schools.

Selective oncolytic effect of an attenuated Newcastle disease virus (NDV-HUJ) in lung tumors.

Newcastle disease virus (NDV), an avian paramyxovirus, has a potential oncolytic effect that may be of significance in the treatment of a variety of cancer diseases. An attenuated lentogenic isolate of NDV (HUJ) demonstrated a selective cytopathic effect upon a panel of human and mouse lung tumor cells, as compared to human nontumorigenic lung cells. The virus-selective oncolytic effect is apoptosis dependent, and related to higher levels of viral transcription, translation and progeny virus formation. Furthermore, NDV-HUJ oncolytic activity is directed in-cis and not through induction of cytokines, that may act in-trans on neighboring cells. Development of primary lung tumors and of the consequent metastasis in mice inoculated with mouse lung tumor cells 3LL-D122 was decreased following treatment with NDV-HUJ. The preferential killing of the tumor cells is not due to a deficiency in the interferon (IFN) system, as expression of the IFN-beta gene, in the infected cells, is properly induced. Moreover, pretreatment with IFN effectively protected the tumor cells from the virus oncolytic effect. We conclude therefore, that NDV-HUJ should have a significant benefit in the treatment of lung cancer as well as other malignancies.

Health care for the poor--an exploration of primary-care physicians' perceptions of poor patients and of their helping behaviors.

This paper explores the ways in which primary-care physicians in Israel perceive and help poor patients. Our findings are based on a qualitative study that utilized a focus group and in-depth interviews with 16 primary-care physicians who qualified both in Israel and in the former Soviet Union, and who work in community clinics one Health Maintenance Organization serving poor populations of diverse cultural, ethnic and socioeconomic backgrounds (immigrants from the former Soviet Union and from Ethiopia, Bedouin, ultra-orthodox Jews, the chronic poor, and the 'new' poor). It was found that the physicians presume causality between poverty and health, identify and distinguish between different types of poverty, and make associations based on the type of poverty and type of patient problem. Their thinking on poverty is patient-oriented rather than socially oriented. An analysis of these findings resulted in a conceptualization of five types of physician helping behavior: emotional and personal instrumental, reinforcing socially desirable behavior, preferential help and bending the rules, rights realization and working the system, and minimal community involvement. The components of this conceptual model depict and chart issues affecting the helping behavior of the primary-care physician, i.e., type of poverty, type of problem, administrative context and, particularly, physician attributes, such as gender and country where notable. Our findings reveal little social consciousness on the part of the physicians, and we conclude with remarks on the potential for change in this area.

The effect of training nursery staff in breastfeeding guidance on the duration of breastfeeding in healthy term infants.

BACKGROUND: Promoting breastfeeding is a central aim of child health care. It is critical to develop approaches that are inexpensive, effective, and suitable across cultural and socioeconomic groups. OBJECTIVE: To study the effect of training perinatal-neonatal nursing and medical staff in breastfeeding guidance on the duration of breastfeeding in a middle-income urban population. METHODS: This was an interventional study with data collection before and after. The intervention was an intensive course on breastfeeding guidance provided to all of the neonatal nurses and midwives in a local general hospital (2001-2002). Data were collected on two cohorts of mothers and infants (before -1999 [n = 471], after -2003 [n = 364]) regarding the duration of breastfeeding and factors influencing its discontinuation. RESULTS: The rate of breastfeeding initiation rose from 84% to 93% (p = 0.0001) and the mean duration of breastfeeding rose from 3.7 +/- 3.7 to 5.6 +/- 4.3 months (p = 0.0001). The rate of breastfeeding in the delivery room rose from 3% to 37% (p = 0.0001). Satisfaction with breastfeeding guidance in the hospital rose from 43% to 79% (p = 0.0001). However, there was no change in the proportion of mothers who planned to breastfeed this infant (88% in both cohorts) and no significant differences in the reasons given by the mothers for stopping breastfeeding. CONCLUSION: Training hospital nursery staff in breastfeeding guidance is a potential, cost-effective intervention even in settings with relatively high rates of breastfeeding.

Detection of Candida species in vaginal samples in a clinical laboratory setting.

OBJECTIVE: To present the detection rates of Candida species in vaginal samples from patients visiting physicians. METHODS: The presence of C. albicans, C. glabrata, C. parapsilosis and C. tropicalis in 3978 vaginal swabs from patients in six US states was detected by PCR amplification. RESULTS: Candida DNA was detected in 33.1% of the population studied. Of the 1316 positive samples, 80.2% contained C. albicans, 14.3% contained C. glabrata, 5.9% contained C. parapsilosis and 8.0% contained C. tropicalis. Comparing samples by patients' state of residence revealed an association with the detection of C. glabrata (p = 0.029). Comparing samples by patients' age revealed a decrease in the overall detection of Candida (p < 0.001) and C. albicans (p < 0.001), concomitant with an increase in the detection of C. glabrata (p < 0.001) and C. parapsilosis (p = 0.025). CONCLUSIONS: These results provide geographic- and age-specific data on four Candida species associated with vaginitis.

Intraoperative ketorolac is an effective substitute for fentanyl in children undergoing outpatient adenotonsillectomy.

BACKGROUND: In this prospective randomized double-blind study, we compared the incidence of emesis and 48-h recovery profiles after a single dose of ketorolac vs fentanyl in dexamethasone-pretreated children undergoing ambulatory adenoidectomy and laser-assisted tonsillectomy (ADLAT). We evaluated the hypothesis that avoiding the use of opioids and replacing them with an equianalgesic dose of ketorolac, a nonsteroidal anti-inflammatory drug, would reduce the incidence of postoperative nausea and vomiting (PONV). METHODS: Fifty-seven ASA I and II children aged 1.710 years who underwent ADLAT were randomized to receive either intravenous ketorolac (1 mg.kg(-1)) or fentanyl (2 microg.kg(-1)) for pain control during a standardized general anaesthetic with propofol infusion. The early (postanaesthesia care unit, day surgical area) and late postoperative courses were compared between the groups. RESULTS: The incidence of PONV was low and equal in both groups. Postoperative pain scores were equal at all stages of followup. Agitation scores in the postanaesthesia care unit were significantly higher in the ketorolac group, but this had no effect on the late variables of behaviour studied. CONCLUSIONS: Ketorolac showed no advantage over fentanyl in reducing the incidence of PONV in children undergoing ADLAT.

Systematic Inventive Thinking: a new tool for the analysis of complex problems in medical management.

The complexity of medical problems is a well-recognized phenomenon. In the presence of economic and cultural restrictions, medical decision-making can be particularly challenging. This paper outlines a system of analysis and decision-making for solving such problems, and briefly describes a case study in which the method was used to analyze the case of antibiotic overprescribing in a large health maintenance organization. The purpose of the study was to determine if a technique for problem-solving in the field of engineering could be applied to the complex problems facing primary care. The method is designated Systematic Inventive Thinking and consists of a three-step procedure: problem reformulation, general search-strategy selection, and an application of idea-provoking techniques. The problem examined is the over-prescribing of antibiotics by general practitioners working in Maccabi Healthcare Services, an HMO serving one and a half million patients in Israel. The group of healthcare professionals involved in the discussions generated 117 ideas for improving antibiotic use. Six of these ideas were then implemented in a national campaign in the winter of 2000/1 and 2001/2. During this period, a significant reduction in per-visit antibiotic purchasing was observed for influenza visits (from 79.2 per 1,000 to 58.1 per 1,000, P < 0.0001), but not for other categories of visits. The SIT methodology is a useful technique for problem-solving and idea generation within the medical framework.

Measured length of normal term infants changes over the first two days of life.

Measured neonatal length may be influenced by reluctance of the measurer to extend the infant's limbs against the normal flexor posture. As the degree of flexion decreases over the first few days of life, measured length may increase. We conducted a study of the effect of postnatal age on measured length and on inter-observer correlation. The study sample consisted of 101 healthy term newborns. Correlation between measurements made before age 2 hours by the study nurse and by regular nurses was excellent with a mean difference of 0.61 +/- 0.49 cm (r2 = 0.923). The mean measured length increased by 0.2 cm between admission and age 1 day (p = 0.057) and by a further 0.17 cm by age 2 days (p = 0.001). This study demonstrates that measured length appears to change over the first 2 days of life.

Pulmonary function threshold for distinguishing ventilatory- and nonventilatory-limited patients with airflow obstruction.

Patients with chronic obstructive pulmonary disease (COPD) may demonstrate great variability between results on the pulmonary function test (PFT) compared to those on the cardiopulmonary exercise test (CPXT). The purpose of this study was to correlate PFT and CPXT indices and to identify PFT threshold values for predicting exercise capacity in patients with airflow limitation. Fifty-seven patients (48 men and 9 women) of mean age 66.4 +/- 4.8 years with COPD and 40 age-matched control patients underwent PFT and CPXT. Based on the CPXT results, the patients were divided into ventilatory-limited (VL) and nonventilatory-limited (NVL), and the findings were correlated with the PFT indices. Linear regression analysis was used to determine the relationship between dyspnea index (VEmax/MVV) and forced expiratory volume in one second (FEV1). The cutoff value for VL was FEV1 < 38% and for NVL FEV1 > 68%. The prominent limiting symptom (61%) in the VL group was dyspnea sensation, with leg discomfort presenting in only 14%; corresponding rates in the NVL group were 38% and 31%. We conclude that the FEV1 is a reliable index for distinguishing VL from NVL COPD patients during CPXT at two extremes: below 38% of the predicted value (VL) and above 68% of the predicted value (NVL).