Minimal impairment in pulmonary function following laparoscopic surgery.

BACKGROUND: Pulmonary function may be impaired in connection with laparoscopic surgery, especially in the head-down body position, but the clinical importance has not been assessed in detail. The aim of this study was to assess pulmonary function after laparoscopic hysterectomy and laparoscopic cholecystectomy. We hypothesised that arterial oxygenation would be more impaired after hysterectomy performed in the head-down position than after cholecystectomy in the head-up position. METHODS: We included 60 women in this prospective, observational study. The patients underwent elective laparoscopic cholecystectomy in the 20° head-up position or hysterectomy in the 30° head-down position. The primary outcome was the difference between arterial oxygenation (PaO2 ) 2 h postoperatively and the preoperative value. Two hours and 24 h after surgery, pulmonary shunt and ventilation-perfusion mismatch were assessed by use of an automatic lung parameter estimation system. RESULTS: Two hours after surgery, the mean change from baseline in PaO2 was -0.65 kPa [95% confidence interval (CI) -3.5 to 3.4, P = 0.14] in the hysterectomy group and -0.22 kPa [95% CI -3.4 to 2.0, P = 0.12] in the cholecystectomy group (P = 0.88). Shunt was significantly greater in the cholecystectomy group 24 h after surgery compared to the hysterectomy group [4%, 95% CI 0 to 9 vs. 0%, 95% CI 0 to 7, P = 0.02]. CONCLUSIONS: Minimal impairment in pulmonary gas exchange was found after laparoscopic surgery. Pulmonary shunt was larger after laparoscopic cholecystectomy, but no clinically significant differences in postoperative pulmonary gas exchange or spirometry were found between laparoscopic hysterectomy and laparoscopic cholecystectomy.

A comparison of the long-term consequences of vaginal delivery versus caesarean section on the prevalence, severity and bothersomeness of urinary incontinence subtypes: a national cohort study in primiparous women.

OBJECTIVE: To study the effect of one vaginal delivery (VD) compared with one caesarean section (CS) on the prevalence, severity and bothersomeness of urinary incontinence (UI) subtypes--stress (SUI), urge (UUI) and mixed (MUI)--20 years after delivery. DESIGN: Registry-based national cohort study. SETTING: Women who returned postal questionnaires (response rate 65.2%) in 2008. POPULATION: Primiparae with one birth in 1985-88 (n = 5236) and no further births. METHODS: Medical Birth Register data were linked to a questionnaire. Analysis of variance and multivariate analysis were used to obtain adjusted prevalences and odds ratios (adjOR). MAIN OUTCOME MEASURES: Prevalence, risk factors, severity, bothersomeness of UI subtypes. RESULTS: The prevalence of SUI, UUI and MUI was 15.3, 6.1, 14.4%, respectively, and was higher for all subtypes after VD versus CS. Moderate to severe incontinence was more prevalent after VD (21.3%) compared with CS (13.5%; adjOR 1.68, 95% confidence interval [95% CI] 1.40-2.03). Bothersome incontinence differed between MUI (38.9%), UUI (27.1%) and SUI (18.0%). The prevalence of bothersome UI was higher after VD compared with CS (11.2 versus 6.3%; adjOR 1.85, 95% CI 1.42-2.39) and consulting a doctor for UI was reported more often after VD than CS. Bothersome MUI occurred in 40.0% of incontinent women after VD compared with 29.9% after CS (adjOR 1.65, 95% CI 1.07-2.54). Symptomatic pelvic organ prolapse was an important modifier of UI with regard to its prevalence, duration, type and bothersomeness. CONCLUSION: The prevalence of SUI, UUI and MUI was higher and moderate to severe UI and bothersome UI were reported more often after VD than CS 20 years after one delivery.

Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery.

OBJECTIVE: To investigate prevalence and risk factors for symptomatic pelvic organ prolapse (sPOP) and sPOP concomitant with urinary incontinence (UI) in women 20 years after one vaginal delivery or one caesarean delivery. DESIGN: Registry-based national cohort study. SETTING: Women who returned a postal questionnaire in 2008 (response rate 65.2%). POPULATION: Singleton primiparae with a birth in 1985-88 and no further births (n = 5236). METHODS: The SWEPOP study used validated questionnaires about sPOP and UI. MAIN OUTCOME MEASURES: Prevalence rate and risk of sPOP with or without concomitant UI. RESULTS: Prevalence of sPOP was higher after vaginal delivery compared with caesarean section (14.6 versus 6.3%, odds ratio [OR] 2.55; 95% confidence interval [95% CI] 1.98-3.28) but was not increased after acute compared with elective caesarean section. Episiotomy, vacuum extraction and second-degree or more laceration were not associated with increased risk of sPOP compared with spontaneous vaginal delivery. Symptomatic POP increased 3% (OR 1.03; 95% CI 1.01-1.05) with each unit increase of current BMI and by 3% (OR 1.03; 95% CI 1.02-1.05) for each 100 g increase of infant birthweight. Mothers ≤ 160 cm who delivered a child with birthweight ≥ 4000 g had a doubled prevalence of sPOP compared with short mothers who delivered an infant weighing < 4000 g (24.2 versus 13.4%, OR 2.06; 95% CI 1.19-3.55). Women with sPOP had UI and UI > 10 years more often than women without prolapse. CONCLUSION: The prevalence of sPOP was doubled after vaginal delivery compared with caesarean section, two decades after one birth. Infant birthweight and current BMI were risk factors for sPOP after vaginal delivery.

The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery.

OBJECTIVE: To investigate the prevalence and risk factors for urinary incontinence (UI) 20 years after one vaginal delivery or one caesarean section. DESIGN: Registry-based national cohort study. SETTING: Women who returned postal questionnaires (response rate 65.2%) in 2008. POPULATION: Singleton primiparae who delivered in the period 1985-1988 with no further births (n = 5236). METHODS: The Swedish Pregnancy, Obesity and Pelvic Floor (SWEPOP) study linked Medical Birth Register (MBR) data to a questionnaire about UI. MAIN OUTCOME MEASURES: Prevalence of UI and UI for more than 10 years (UI > 10 years) were assessed 20 years after childbirth. RESULTS: The prevalence of UI (40.3 versus 28.8%; OR 1.67; 95% CI 1.45-1.92) and UI > 10 years (10.1 versus 3.9%; OR 2.75; 95% CI 2.02-3.75) was higher in women after vaginal delivery than after caesarean section. There was no difference in the prevalence of UI or UI > 10 years after an acute caesarean section or an elective caesarean section. We found an 8% increased risk of UI per current body mass index (BMI) unit, and age at delivery increased the UI risk by 3% annually. CONCLUSIONS: Two decades after one birth, vaginal delivery was associated with a 67% increased risk of UI, and UI > 10 years increased by 275% compared with caesarean section. Our data indicate that it is necessary to perform eight or nine caesarean sections to avoid one case of UI. Weight control is an important prophylactic measure to reduce UI. Current BMI was the most important BMI-determinant for UI, which is important, as BMI is modifiable.

The influence of smoking on bone loss and response to nasal estradiol.

OBJECTIVE: To investigate the influence of smoking on bone during therapy with nasally administrated estradiol in sequential combination with oral progesterone in early postmenopausal women. In addition, to observe the consequences of smoking on bone in untreated women. METHODS: Post-hoc exploratory analyses of data from 270 postmenopausal women randomized to 2 years' therapy with daily nasal administration of 17beta-estradiol or placebo sequentially combined with oral micronized progesterone in the active groups or placebo in the placebo group. RESULTS: During treatment with nasal estradiol, the bone mineral density (BMD) of the lumbar spine had increased less at 2 years in smokers as compared to non-smokers (2.6% vs. 3.9%, p = 0.03). Parallel changes were seen in the placebo group (-3.6% vs. -2.4%, p = 0.08). In the total hip BMD, there was no difference in the response to estradiol in smokers vs. non-smokers (1.4% vs. 1.4%, p = 0.89), whereas the change in the hip on the placebo was similar to that seen in the spine (-3.7% vs. -2.6%, p = 0.08). Supportive changes were seen in urinary CTX and in serum osteocalcin. CONCLUSIONS: These results indicate that cigarette smoking may reduce the efficacy of nasal estradiol to increase bone mass in early postmenopausal women. In addition, smoking may increase spontaneous bone loss in untreated women.

Surveillance of health status on eight marine rainbow trout, Oncorhynchus mykiss (Walbaum), farms in Denmark in 2006.

The health status of eight marine rainbow trout farms was followed from mid-June to mid-September 2006 by sampling both dead and healthy fish approximately every 2 weeks for bacteriological and virological investigation. No fish pathogenic viruses were detected, but all farms experienced disease and mortality as a result of various bacterial infections. Yersinia ruckeri was found on four and Renibacterium salmoninarum on five of the farms, but only during the first part of the surveillance period. This indicates that the fish carried the infection from fresh water, and cleared the infection in salt water. Aeromonas salmonicida subsp. salmonicida caused mortality on five farms, but persisted throughout the sampling period. Although A. salmonicida was probably carried from fresh water, the fish were not able to clear the infection in the sea. Vibrio anguillarum caused mortality on six of the farms throughout the sampling period, O1 being the dominant serovar, and Photobacterium damselae subsp. damselae was found on seven farms as a cause of disease. During the period of highest water temperatures Vibrio parahaemolyticus and Vibrio vulnificus were detected in dead fish in five and two farms, respectively, although their significance as causative pathogens is questionable. Vibrio vulnificus has not previously been found in rainbow trout in Denmark. Both mortality and number of antimicrobial treatments during the period were considerably higher in unvaccinated compared with vaccinated fish. Resistance to commonly used antimicrobials was low or absent.

Appendicitis in pregnancy: diagnosis, management and complications.

BACKGROUND: Acute appendicitis is the most common surgical emergency in pregnancy. The purpose of this study is to investigate the clinical presentation, management and outcome in patients who underwent appendectomy during pregnancy. MATERIAL AND METHODS: The case records of 56 women who underwent appendectomy during pregnancy between January 1985 and December 1997 were reviewed and analyzed. RESULTS: The incidence of appendicitis in pregnancy was one in 766 births. The preoperative diagnosis was correct in 75% of the cases. Uterine contractions and a history of diffuse or periumbilical pain migrating to the right lower abdominal quadrant were significantly more frequent among women with appendicitis compared to those patients where the appendectomy revealed a normal appendices. Abdominal pain, nausea, vomiting, leukocyte count, CRP and body temperature were not helpful in establishing the correct diagnosis. There was no maternal morbidity related to the appendectomy. Pregnancy complications were found to be considerable: 4/12 (33%) who underwent appendectomy for appendicitis during the first trimester aborted spontaneously. Second trimester appendectomy for appendicitis was followed by premature delivery in 4/28 (14%). However, no pregnancy complications were observed following third trimester appendectomy for appendicitis. We found no increase in pregnancy complications in cases with perforated appendicitis. CONCLUSION: Appendicitis in pregnancy should be suspected when a pregnant woman complains of new abdominal pain. No laboratory finding was found to be diagnostic for acute appendicitis during pregnancy. Considerable fetal loss was found after appendectomy during pregnancy in the first and second trimester. No increase in pregnancy complications in cases with perforated appendicitis was observed. The combination of symptoms and clinical judgement is still vital in deciding which patient needs surgical treatment. Based on the results in the present study we recommend prophylactic antibiotic treatment in all laparotomies during pregnancy when appendicitis is suspected.

Inhibition of vibrio anguillarum by Pseudomonas fluorescens AH2, a possible probiotic treatment of fish.

To study the possible use of probiotics in fish farming, we evaluated the in vitro and in vivo antagonism of antibacterial strain Pseudomonas fluorescens strain AH2 against the fish-pathogenic bacterium Vibrio anguillarum. As iron is important in virulence and bacterial interactions, the effect of P. fluorescens AH2 was studied under iron-rich and iron-limited conditions. Sterile-filtered culture supernatants from iron-limited P. fluorescens AH2 inhibited the growth of V. anguillarum, whereas sterile-filtered supernatants from iron-replete cultures of P. fluorescens AH2 did not. P. fluorescens AH2 inhibited the growth of V. anguillarum during coculture, independently of the iron concentration, when the initial count of the antagonist was 100 to 1, 000 times greater that of the fish pathogen. These in vitro results were successfully repeated in vivo. A probiotic effect in vivo was tested by exposing rainbow trout (Oncorynchus mykiss Walbaum) to P. fluorescens AH2 at a density of 10(5) CFU/ml for 5 days before a challenge with V. anguillarum at 10(4) to 10(5) CFU/ml for 1 h. Some fish were also exposed to P. fluorescens AH2 at 10(7) CFU/ml during the 1-h infection. The combined probiotic treatment resulted in a 46% reduction of calculated accumulated mortality; accumulated mortality was 25% after 7 days at 12 degrees C in the probiotic-treated fish, whereas mortality was 47% in fish not treated with the probiont.

Reduction of sick leave for lumbar back and posterior pelvic pain in pregnancy.

STUDY DESIGN: In this prospective, consecutive, controlled cohort study, the authors analyzed the impact of a differentiated, individual-based treatment program on sick leave during pregnancy for women experiencing lumbar back or posterior pelvic pain during pregnancy. OBJECTIVE: To identify patients with pain early in pregnancy and, by means of individual information and differentiated physiotherapy, reduce sick leave during pregnancy. SUMMARY OF BACKGROUND DATA: Sick leave for back pain during pregnancy is common, and treatment programs have been aimed at reducing pain, for that reason. In Sweden, the average sick leave due to back pain during pregnancy is 7 weeks. METHODS: All pregnant women who attended a specific antenatal clinic and experienced lumbar back or posterior pelvic pain were included in an intervention group, and results were compared with women in a control group from another antenatal clinic. RESULTS: The intervention group comprised 54 women, compared with 81 women in the control group. Thirty-three women were on sick leave for an average of 30 days in the intervention group versus 45 women for an average of 54 days in the control group (P < 0.001). The reduction in sick leave reduced insurance costs by approximately $53,000 U.S. CONCLUSIONS: Sick leave for lumbar back and posterior pelvic pain in the intervention group was significantly reduced with the program, and the program was cost effective.

mRNA profiling of rat islet tumors reveals nkx 6.1 as a beta-cell-specific homeodomain transcription factor.

Development of a high capacity multiplex reverse transcriptase-polymerase chain reaction protocol has allowed us to screen lineage related rat islet tumors classified as alpha-, beta-, and delta-like as judged by their hormone profile for differential expression of more than 50 selected genes. We find that in addition to insulin the insulinoma express the normal beta-cell markers Pdx-1, IAPP, and Glut-2, and that these markers are absent from the glucagonoma: a reflection of the normal alpha-cell. Furthermore, this study suggests that the GLP-1, glucagon, GIP, IGF-1, and insulin receptors as well as E-cadherin, R-cadherin, Id-1, and Id-2 are differentially expressed within the islet of Langerhans. Importantly, insulinoma-specific expression of the recently cloned homeodomain protein Nkx 6.1 predicted beta-cell-specific expression in the normal islet. Immunohistochemistry using antibodies raised against recombinant Nkx 6.1 did indeed localize Nkx 6.1 expression exclusively to the nuclei of normal islet beta-cells. Apart from pancreatic islets only the antral part of the stomach contained Nkx 6.1 mRNA. We conclude that multiplex reverse transcriptase-polymerase chain reaction-based mRNA profiling is a powerful tool to identify differentially expressed genes within phenotypically related cells and propose that Nkx 6.1 is involved in specifying the unique characteristics of the beta-cell.

[Prognosis in familial adenomatous polyposis. Results from the Polyposis Registry]. / Prognosen ved familiaer adenomatøs polypose. Resultater fra polyposeregistret.

Regional and national polyposis registries have been established all over the world over last decades, with the aim to improve survival in patients with familial adenomatous polyposis (FAP). The Danish Polyposis Register was founded in 1971 and coordinates screening and prophylactic treatment. At the end of 1992 the register included 321 histologically verified FAP patients: 142/205 probands (69%) had colorectal cancer at the time of diagnosis of FAP versus only 2/116 call-up cases (2%). The 10-year cumulative crude survival was 94% among call-up cases versus only 41% among probands (p < 0.00001), and the survival increased significantly after establishment of the Polyposis Register in 1971. We conclude that centralized registration with identification and prophylactic examination of relatives at risk results in a substantial improvement of the prognosis.

Centralized registration, prophylactic examination, and treatment results in improved prognosis in familial adenomatous polyposis. Results from the Danish Polyposis Register.

BACKGROUND: Over the last few decades numerous regional and national registers have been established all over the world with the aim of improving survival in familial adenomatous polyposis (FAP). The Danish Polyposis Register was founded in 1971 and coordinates the screening and subsequent prophylactic colectomy of FAP patients. METHODS: The crude cumulative survival in 321 patients (205 probands and 116 call-up cases) with verified FAP was calculated in accordance with the life-table method. RESULTS: At the time of diagnosis of FAP only 2 of 116 (2%) had colorectal cancer versus 142 of 205 probands (69%). The 10-year cumulative survival was 94% (95% confidence limits, 89-99) in call-up cases compared with only 41% (34-49) in probands (p < 0.00001), and survival improved significantly (p < 0.00001) after the establishment of the Danish Polyposis Register. CONCLUSION: The establishment of a centralized polyposis register has resulted in a substantial improvement of the prognosis in FAP.

The cesarean section rate in Sweden: the end of the rise.

This nationwide study examined the annual changes in cesarean section rates in relation to perinatal mortality, the condition of the newborn at birth, and different indications for the procedure in Sweden. Since 1973 all obstetric units have sent copies of medical birth registration forms for newborns to the National Board of Health and Welfare. Information about the cesarean section rate, indications for the surgery, Apgar scores, and perinatal mortality between 1973 and 1990 was obtained from this data base. The cesarean section rate increased from 5 percent in 1973 to 12.3 percent in 1983, and thereafter declined steadily to 10.84 percent in 1990. Perinatal mortality was halved from 14.2 to 6.3 per 1000 live births, and the number of newborns with low Apgar scores (< 4 at 1 min and/or < 7 at 5 min) decreased from 20 to 14 per 1000 live births. We conclude that it is possible to lower the cesarean section rate on a nationwide basis without increasing risks to newborn infants.

Rupture and dehiscence of cesarean section scar during pregnancy and delivery.

A prospective study was undertaken to evaluate the risk of uterine rupture or dehiscence after cesarean section. During the 10 years of the study, 24,644 patients were delivered of infants. Of these women, 2036 (8.3%) had previously undergone cesarean section. A trial of labor was allowed in 1008 of these patients, and 92.2% were delivered vaginally. The incidence of uterine rupture in this trial of labor group was 0.6%, compared with 0.4% in the total group. Cesarean section scar rupture caused no serious complications in either the mothers or the offspring in the trial of labor group. Uterine rupture in this group was not associated with use of oxytocin or epidural analgesia. Patients with lower-segment scar rupture had no history of puerperal pyrexia. The incidence of uterine dehiscence was 4%. In summary, the risk of uterine rupture in patients who have previously undergone cesarean section but are allowed a trial of labor is low and not associated with serious complications. Vaginal delivery is therefore considered the safest route of delivery in these patients.

Placenta previa and antepartum hemorrhage after previous cesarean section.

A prospective study was conducted to determine the risk of placenta previa and unexplained antepartum hemorrhage after a previous cesarean section (CS). Of a total of 24,644 patients, 81 (0.33%) had a placenta previa which demanded abdominal delivery. The risk of placenta previa was 0.25% with an unscarred uterus and 1.22% in patients with one or more previous CS (the difference was statistically significant p less than 0.001). The corresponding figures for unexplained antepartum hemorrhage were 0.40% and 3.81%, respectively (p less than 0.001). Patients presenting with a placenta previa and a scarred uterus had a 16% risk of undergoing cesarean hysterectomy because of placenta accreta and severe hemorrhage compared to 3.6% in patients with placenta previa and an unscarred uterus. In conclusion, cesarean deliveries predispose to placenta previa, placenta accreta and antepartum hemorrhage during subsequent pregnancies. This relationship has to be considered in the cost-benefit equation for decision of route of delivery.

Cesarean section: a controversial feature of modern obstetric practice.

Cesarean section (CS) has been an integral part of modern obstetrics during the last decades. As safety has increased, so too has the range of problems that CS is used to solve, to a degree that it must cause medical concern. There is a great danger in the blind faith that CS is the only way out in every difficult obstetric situation. The problem can always be easily solved by CS in an acute difficult obstetrical situation. However, CS is a major abdominal surgery and it may present any complication that besets major surgery including severe intraoperative and postoperative complications, a much greater risk for maternal death compared to vaginal delivery and also late complications, i.e. secondary involuntary infertility. Therefore, CS should never be undertaken lightly and without serious consideration of the justifications, preparations and all ancillary support.