Transverse Vaginal Septum Resection: Technique, Timing, and the Utility of Dilation. A Scoping Review of the Literature.

STUDY OBJECTIVE: Transverse vaginal septae (TVS) are congenital, obstructive anomalies of the vagina typically presenting with abdominal pain and amenorrhea. Currently, the literature about surgical management is sparse. Postoperative complications are common. Vaginal dilation either pre- or postoperatively is sometimes recommended, the outcomes of which are poorly described. The aim of this scoping review was to guide surgical planning, namely, timing and postoperative care, to improve surgical outcomes. DESIGN, SETTING, PARTICIPANTS, AND MAIN OUTCOME MEASURES: This scoping review followed the Joanna Briggs Institute framework. The population of interest was patients 21 years of age or younger with a TVS. MEDLINE, OVID and CINAHL databases were searched using the subject headings listed herein. Literature written in English and French were included. Excluded were reports on patients with concurrent urogenital anomalies or severe developmental disabilities. The resultant articles were reviewed by 2 independent researchers. A third researcher was used in cases of disagreement. Using a descriptive analytical method, data were extracted from the included articles. RESULTS: We screened 1441 articles for eligibility; 41 articles met criteria, which described 152 cases of TVS. The most common management was simple vaginal excision. Five studies included outcomes from preoperative dilation, and 11 from postoperative dilation. There were 21 cases of postoperative vaginal stenosis; half (11/21) occurred without postoperative dilation. CONCLUSION: The goal of this review was to describe how TVS are managed and provide guidance for management options. Although the literature was sparse, the authors believe that management in a tertiary center, and surgical delay until the patient is ready to participate in vaginal dilation will improve outcomes for patients with TVS. Further prospective studies are needed to guide surgical planning.

Implications of Ehlers-Danlos Syndrome in a Patient With Mayer-Rokitansky-Küster-Hauser Syndrome.

BACKGROUND: Ehlers-Danlos syndromes (EDS) are a heterogenous group of connective tissue disorders characterized by defective collagen production. Patients with EDS have lax and fragile connective tissue in their joints, skin, blood vessels, and hollow organs. This can lead to, among other complications, joint hypermobility, aneurysms, organ prolapse, and musculoskeletal chronic pain. Given that patients with vaginal agenesis, which occurs with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, often require vaginal dilation as part of their treatment, tissue elasticity and fragility are important considerations. This case report aims to describe the intersection of MRKH and EDS and its impact on vaginal dilation. CASE: A 16-year-old girl with joint hypermobility and type III EDS presented with primary amenorrhea and a karyotype of 46 XX. Magnetic resonance imaging confirmed an absent uterus, cervix, and upper vagina. Physical examination showed Tanner V breasts and Tanner IV pubic hair, and an external genital examination revealed a blind-ending, 1-cm vaginal dimple. The patient was diagnosed with MRKH. Following her diagnosis, she received vaginal dilation instruction and returned for follow-up 2 months later, having quickly progressed to the largest vaginal dilator without symptoms of bleeding, pain, or dysuria. In that timeframe, her vaginal dimple had increased from 1 cm to 7-8 cm in depth, a rate much faster than is typically seen. Because of this rapid progress, a urogenital examination was performed. There was no evidence of urethral abnormality, perforation, or vaginal prolapse. SUMMARY AND CONCLUSION: Recognition of EDS in patients with Müllerian anomalies has important implications for safe and effective vaginal dilation. All patients using vaginal dilation to lengthen the vagina require education on the technique. This need is heightened in patients with EDS in order to prevent accidental dilation of the urethra due to their tissue elasticity, to avoid tissue prolapse, and to prevent the theoretical risk of vaginal perforation.

Panniculitis, due to Mycobacterium smegmatis, in two Finnish cats.

Pyogranulomatous panniculitis due to infection by Mycobacterium smegmatis was diagnosed in two cats in Finland, a country with a rather cold climate. The diagnosis was confirmed by sequencing of the 16S rRNA gene, which gave a perfect match with the M smegmatis strain ATCC 19420. Gene sequencing makes it possible to distinguish M smegmatis from closely related mycobacteria such as M goodii sp.nov. Diagnosing this entity seems to be a question of having a high index of suspicion. The appearance of the disease as well as sampling is described in detail. In our first case an initial erroneous diagnosis of Nocardia species considerably delayed our arriving at the right diagnosis. The first patient has now been followed for more than 7 years. Her disease is chronic, but she is not systemically affected. Several antimicrobials were tried. Probable side effects of enrofloxacin medication are described.

Pulmonary infection caused by an unusual, slowly growing nontuberculous Mycobacterium.

Mycobacterium triplex, a recently described slowly growing nontuberculous mycobacterium, was isolated from a Finnish patient with pulmonary mycobacteriosis. The disease was successfully treated with antimycobacterial drugs. The strain isolated, which was similar to the type strain but differed slightly from the species description, was regarded as a variant of M. triplex sensu stricto. According to present knowledge this variant of the species has never been isolated before.

Osteitis caused by bacille Calmette-Guérin vaccination: a retrospective analysis of 222 cases.

To evaluate the frequency, clinical features, and prognosis of patients with osteitis caused by bacille Calmette-Guérin (BCG) vaccination, medical records from Finnish children based on nationwide registration from 1960 to 1988 were retrospectively analyzed. During the study period, three different BCG vaccine preparations were used. In 222 children, diagnostic criteria of BCG osteitis were fulfilled. The age at onset of BCG osteitis varied from 0.25 to 5.7 years. The most common sites of osteitis were metaphyses of the long bones. The lower extremity (58%) was affected more often than the upper (14%). Osteitis was situated in the sternum in 36 patients (15%) and in the ribs in 27 (11%). The frequency of BCG osteitis, but not the clinical parameters, was closely associated with the vaccine preparation used. Only 6 children were left with some sequelae. With adequate treatment, the prognosis for children vaccinated with BCG is good.

Osteitis after newborn vaccination with three different Bacillus Calmette-Guérin vaccines: twenty-nine years of experience.

Newborns in Finland have been vaccinated with Bacillus Calmette-Guérin (BCG) since the 1950s. Until the end of 1970 the vaccine was made from BCG strain Gothenburg by the Swedish BCG laboratory in Gothenburg and from 1971 on from the same strain in Copenhagen, Denmark. It was replaced by the Glaxo vaccine in 1978. Complications caused by BCG vaccination have been under follow-up, and the data have been collected from nationwide registers. In this study we analyzed the incidence rates of BCG osteitis between the years 1960 and 1988. From 1960 to 1970 the incidence rate was from 2.7 to 13.0/100,000 BCG-vaccinated infants (mean, 7.3; median, 6.9). The incidence increased during the years 1971 to 1978 when it varied between 15.3 and 72.9/100,000 BCG-vaccinated infants (mean, 36.9; median, 30.4). Since 1978 the incidence has varied between 1.7 and 10.1/100,000 BCG-vaccinated infants (mean, 6.4; median, 7.2). In Britain no reports of BCG osteitis have been published despite the use of the same Glaxo vaccine. Our results indicate that the incidence of BCG osteitis in a given population depends on the BCG vaccine used. The follow-up of BCG complications is an essential part of BCG vaccination program.

Risk of infection with Mycobacterium tuberculosis among children and mothers in Somalia.

The prevalence of infection with Mycobacterium tuberculosis in prewar Somalia was surveyed by testing the tuberculin sensitivity of 2,792 infants and children and 446 mothers in two towns: Burao in the dry north and Kismayo in the humid south. Sensitivity increased with age, but considerable differences prevailed between the towns. In Burao a roughly linear increase in sensitivity was found, with no sensitivity in infancy, sensitivity in 19% of children at 7 years, and sensitivity in 54% of children at 15 years; in Kismayo the corresponding figures were 9%, 28%, and 47%, respectively. Together, the correlation of prior BCG vaccination with a positive tuberculin test in Burao and the lack of these findings in Kismayo suggested that vaccination had partly failed in Kismayo, where living conditions also favored the transmission of M. tuberculosis. The annual risk of M. tuberculosis infection was approximately 1% higher in the south than in the north and was much higher during the first 3 years of life than later. This study--the first defining the risk of M. tuberculosis infection among children of various ages in Somalia--indicates that this risk is greatest in the southern parts of the country and among infants and young children.

Rapid decrease in tuberculin skin test reactivity at preschool age after newborn vaccination.

A study of tuberculin sensitivity was performed in 353 children aged 4-6 years, all vaccinated at birth with British BCG vaccine. Significant waning of tuberculin reactions with increasing age was found (p < 0.05). In the age group < 4.5 years, the mean tuberculin reaction was 6.6 mm, in the age group 4.5-5.5 years 5.2 mm and in the age group of > 5.5 years 3.5 mm. The number of children with positive reactions (> or = 5 mm) was 165 (40%) and those with strong reactions (> or = 10 mm) 49 (14%). None of the latter children had active tuberculosis during a follow-up period of 12 months. Eighty-three (24%) of the children had no reaction. The children who had been revaccinated with the MPR vaccine against measles, rubella and parotitis (n = 31) had significantly larger tuberculin reactions than the non-revaccinated children. Atopic dermatitis or infections during the preceding six months did not have any significant influence on reaction sizes. Our results demonstrate that the variation in size of tuberculin reactions after BCG vaccination at birth is large. We conclude that tuberculin sensitivity wanes rapidly by the age of 4.0-6.3 years.

Characterization of a distinct group of slowly growing mycobacteria by biochemical tests and lipid analyses.

A group of slowly growing mycobacterial strains (n = 14) isolated from respiratory tract specimens was collected from 1971 to 1990 on the basis of growth characteristics and uncommon biochemical and glycolipid profiles. Growth at 25 to 45 degrees C, a negative Tween 80 hydrolysis test, a strong positive reaction in a 14-day arylsulfatase test, and susceptibility to ethambutol in combination with resistance to cycloserine were important for the initial separation. The strains had a distinctive glycolipid pattern which was unlike those of other mycobacterial species. Analyses of cellular fatty acids by gas-liquid chromatography and mycolic acids by thin-layer chromatography further characterized this homogeneous group of mycobacteria. The presence of 2-eicosanol (2-OH-20:0alc) and hexacosanoic acid (26:0) combined with the lack of 2-docosanol (2-OH-22:0alc) differentiated this group from other slowly growing mycobacteria.

Chemotypes of Mycobacterium malmoense based on glycolipid profiles.

Thin-layer chromatographic analysis of 72 Finnish clinical mycobacterial isolates presumptively identified as Mycobacterium malmoense revealed four major glycolipid profiles with two minor variations. An additional glycolipid profile was found in three British M. malmoense-like strains. No clear distinction between the strains could be made by means of gas chromatography of cellular fatty acids. The two M. malmoense-specific constituents, 2-methyleicosanoate and 2,4,6-trimethyltetracosanoate, were detected in all strains. The frequency of chemotypes other than that of the type strain was 8% among the Finnish isolates. This variation should be recognized when confirmative identification of mycobacteria is based on thin-layer chromatography of glycolipid extracts.

Enhancement of growth of Mycobacterium malmoense by acidic pH and pyruvate.

The growth of Mycobacterium malmoense is dysgonic and slow on ordinary mycobacterium media. The effect of pH and pyruvate on the growth of ten strains was studied on a modification of Löwenstein-Jensen medium. Growth appeared sooner and was more abundant at pH less than 6.5. At pH 7 or higher, it was scarcely or not at all visible after six weeks of incubation. Pyruvate enhanced the growth of five strains that grew only poorly on glycerol-containing medium, even at acidic pH. The parallel use of both pyruvate and glycerol-containing media, pH 6 to 6.5, and an incubation period of seven weeks or longer are recommended for the isolation of Mycobacterium malmoense on Löwenstein-Jensen medium.

Crystalline cell surface layer of Mycobacterium bovis BCG.

A paracrystalline surface layer (S layer) was found as the outermost layer of the cell wall of five Mycobacterium bovis BCG strains. An oblique arrangement of the subunits in the S layer was only clearly seen in thin-sectioned and shadowed preparations, and the unit constant was about 5.5 nm.

Mycobacterium xenopi: identification of different chemotypes based on the lipid pattern analysis by TLC.

Mycobacterium xenopi, considered as a homogenous species when identified by conventional phenetic markers (Runyon et al. 1974), was subdivided into three distinct chemotypes described here.

Neonatal BCG vaccination and mycobacterial cervical adenitis in childhood.

Mycobacterial cervical adenitis is an uncommon disease in children in Finland. During 10 years, from 1977-1986, its incidence was of the order of 0.3/year/100,000 children. Of the 12 bacteriologically verified cases, M. avium-intracellulare was isolated in nine, M. malmoense in two and M. tuberculosis in only one case. Neonatal BCG vaccination seemed to protect children against non-tuberculous mycobacterial infection, especially at 1-4 years of age. In Sweden, where neonatal BCG vaccination has been discontinued, the incidence of non-tuberculous mycobacterial adenitis is at least 30 times greater.

Ornithine decarboxylase, S-adenosyl-L-methionine decarboxylase and arginine decarboxylase from Mycobacterium bovis (BCG).

Ornithine decarboxylase (ODC), S-adenosyl-L-methionine decarboxylase (AMDC) and arginine decarboxylase (ADC) activities were detected for the first time in extracts of Mycobacterium bovis (BCG). All the decarboxylases differed from corresponding known bacterial decarboxylases in that: a) ODC did not require GTP for activity; b) ODC was not inhibited by any known inhibitor of bacterial ODCs; c) AMDC and ADC did not require Mg2+-ion for activity and were not markedly inhibited by any known inhibitor of the decarboxylases of other bacteria.