Lower gastrointestinal bleeding in pregnancy: Differential diagnosis, assessment and management.

Rectal bleeding is a common symptom experienced by pregnant women. Although the majority of cases are attributable to benign conditions such as haemorrhoids and anal fissures, other more serious diagnoses such as inflammatory bowel disease and malignancy should not be overlooked. Most investigations are safe during pregnancy and these should not be withheld as significant implications on both fetal and maternal morbidity may result. In these cases, a multidisciplinary team approach is essential. This review explores the differential diagnosis, investigation and management of rectal bleeding during pregnancy.

Missed opportunities for ovarian salvage in children: an 8-year review of surgically managed ovarian lesions at a tertiary pediatric surgery centre.

INTRODUCTION: The aetiology and management of ovarian pathology in children differs between antenatal and postnatal lesions. However, all lesions may present acutely due to adnexal torsion. In this setting, opportunities to preserve fertility with ovary-sparing surgery (OSS) may be missed. Some studies suggest that pediatric and adolescent gynaecology (PAG) input in care is associated with OSS. METHODS: A retrospective cohort study of children undergoing surgery for ovarian pathology at a tertiary pediatric surgery centre over an 8-year period (2011-2018). Patient factors, lesion characteristics and PAG involvement were examined for association with OSS using multivariate logistic regression. RESULTS: Thirty-five patients with ovarian pathology managed surgically were included. Ten were infants with lesions detected antenatally; all were managed by pediatric surgeons (PS) alone at median age 2 weeks (1 day-25 weeks). Twenty-five patients presented postnatally at median age 11 (0.75-15) years. In total, there were 16 cases of adnexal torsion, each managed primarily by PS. Twelve underwent oophorectomy and six (50%) of these cases had viable ovarian tissue on histology. Furthermore, two infants with large simple cysts were similarly managed by unnecessary oophorectomy based on histology. Overall rate of OSS was 46% and PAG involvement was the only factor associated with ovarian salvage. CONCLUSION: Differences in surgical management between PAGs and PS may be attributable to the different patient populations they serve. We recommend improving the knowledge of PS trainees in OSS approaches for adnexal torsion and large benign lesions.

The use of antenatal fetal magnetic resonance imaging in the assessment of patients at high risk of preterm birth.

Preterm birth, defined as birth occurring prior to 37 weeks gestation is a common obstetric complication affecting 8% of pregnancies and is associated with significant morbidity and mortality. Infection/inflammation has been implicated in both the aetiology of preterm birth itself and associated neonatal pulmonary and neurological morbidity. Treatment options are currently limited to prolongation of the pregnancy using cervical cerclage, pessaries or progesterone or administration of drugs including steroids to promote lung maturity and neuroprotective agents such as magnesium sulphate, the timing of which are highly critical. Although delivery is expedited in cases of overt infection, decisions regarding timing and mode of delivery in subclinical infection are not clear-cut. This review aims to explore the use of magnetic resonance imaging (MRI) in the antenatal assessment of pregnancies at high risk of preterm birth and its potential to guide management decisions in the future.

Cervical cerclage: an established intervention with neglected potential?

Cervical cerclage is a common obstetric procedure, performed in an attempt to reduce the likelihood of late miscarriage and preterm delivery. Many questions still remain unanswered, however, regarding its efficacy and the populations most likely to benefit. Existing studies often use endpoints such as preterm delivery, but associations between preterm birth and more long-term health effects such as neurodevelopmental sequelae are well reported. Such endpoints have often not been addressed in many of the studies to date. This article reviews and appraises the literature and evidence regarding cervical cerclage as well as addressing the questions that, as yet, remain unanswered.

Placental MRI in intrauterine fetal growth restriction.

OBJECTIVE: Our objectives were to determine if MR imaging of the placenta could demonstrate a specific placental phenotype in small for gestational age fetuses with increasing severity of fetal growth restriction, and if MRI findings at the time of scan could be used to predict fetal or neonatal mortality. METHOD: We included singleton growth restricted fetuses with increasing severity of fetal growth restriction secondary to placental insufficiency. 20 growth restricted fetuses and 28 normal fetuses were scanned once during pregnancy at varying gestations. MRI scans were performed on a 1.5T system using ssFSE sequences through the uterus. Data was collected on the severity of fetal growth restriction and pregnancy outcome, including clinical neonatal details, perinatal mortality, and birthweight and centile. Placental volume, maximal placental thickness, the placental thickness to volume ratio, the placenta to amniotic fluid signal intensity ratio, and the presence of abnormal signal intensity consistent with placental pathology were noted. In a subset of patients, histopathological diagnosis was compared with the MRI appearance of the placenta. RESULTS: There was a significant increase in the placental volume affected by pathology in growth restricted fetuses (p < 0.001). The placental appearance was also thickened and globular, with an increase in the placental thickness to volume ratio (p < 0.001). Although placental volume increased with increasing gestation, it remained reduced in the growth restricted fetuses (p = 0.003). There was a significant correlation between the severity of fetal growth restriction and the placental volume affected by pathology, the placental thickness to volume ratio, and the placental volume. ROC analysis showed that fetal or neonatal death was predicted by the percentage of abnormal signal intensity consistent with placental pathology (p = 0.002). The presence of a thickened, globular placenta and a maximal placental thickness to volume ratio above the 95% confidence limit for gestation was significantly associated with an increased incidence of fetal or neonatal mortality (relative risk = 1.615, p = 0.001 and relative risk = 7, p < 0.001). CONCLUSIONS: The MRI appearance of the placenta provides an indication of the severity and underlying disease process in fetal growth restriction. In units where MRI imaging of the growth restricted fetus occurs, we suggest that the assessment of the placenta should also occur as it may contribute to management decisions in cases at the threshold of viability. It may have a role to play in monitoring disease severity, and the effect of future interventions designed to improve placental function.

Multilocus enzyme electrophoretic (MEE) analysis of Australian isolates of Salmonella enteritidis.

Seventy-three Australian isolates of Salmonella Enteritidis (SE) were analysed by multilocus enzyme electrophoresis (MEE) using a polyacrylamide gel system. Analysis of 11 enzyme loci identified eight electrophoretic types (ETs), with 61 of the isolates assigned to ET1, and 72 isolates considered to represent a clonal lineage. Representative isolates of each of the Australian ETs were then compared with isolates from England, Germany and the United States, using a starch gel system and 13 enzyme loci. The overseas isolates formed a single ET with representatives of the major Australian ET. It is concluded that Australian isolates of SE are closely related genetically to those from countries in which egg-borne transmission is common.

A survey of preferred approach to inguinal hernia repair: laparoscopic or inguinal incision?

The recent interest in laparoscopic surgery has raised some concerns that large numbers of surgeons were recommending this "minimally invasive" approach in procedures such as inguinal herniorrhaphy before the availability of adequate data regarding safety and benefits. To determine current experience and preference levels for laparoscopic inguinal herniorrhaphy (LH), we conducted a mail survey of New Jersey surgeons. Of 531 respondents, 430 (81%) preferred a traditional inguinal incision approach over a laparoscopic approach (8%). Of 344 general surgeon respondents, 227 (66%) had experience with laparoscopic cholecystectomy, but only 56 (16%) had experience with LH. This latter group had performed only an average of 9.2 laparoscopic herniorrhaphies, with a median of five cases. Most of these 56 surgeons with LH experience indicated a preference for inguinal incision herniorrhaphy although 19 surgeons who had performed 10 or more LH cases showed a slight preference for LH (11 to 8). The primary reasons for choosing LH included "less pain" and "quicker recovery." The primary reasons for choosing inguinal incision herniorrhaphy included having a "better known procedure" and avoiding general anesthesia. Our survey indicates that the laparoscopic approach to inguinal hernia repair has currently accumulated few proponents in the surgical community since many surgeons are waiting for more data on the procedure.

Treatment effectiveness outcome research in adult partial hospitalization.

The pilot study at Charter Kingwood was designed as an integral part of continuous quality improvement. Research focused on patient appropriateness and outcome treatment results. The Day Therapy Appropriateness Scale was administered along with pre and post tests of the Index of Self Esteem (ISE) and General Contentment Scale (GCS). Other instruments included a Patient Satisfaction Survey and alumni quarterly follow-up checklist letter. The outcome study demonstrates that patients were appropriately placed in treatment and improved with treatment. Results showed that patients improved 20% after 2 weeks of intensive group therapies. The Patient Satisfaction Survey had 17 items and 4 categories to select degrees of satisfaction or dissatisfaction with the overall program, staff, therapy groups, and individualized treatment goals. Results supported a 90% overall satisfaction with services provided. An alumni quarterly follow-up emphasizing postdischarge planning and aftercare verified that 96.3% of participants benefited from the program, 82% participated in aftercare, and 98.3% would recommend significant others for treatment.

Metabolic effects of fructose supplementation in diabetic individuals.

With new diabetes diet guidelines recommending high carbohydrate intake, questions arise regarding acceptable intake of simple sugars. Whereas several short-term studies report flattened glycemic and insulin response to fructose consumption, some also report increased serum triglyceride levels. Few studies examine the effects of long-term fructose consumption. We evaluated the long-term safety of fructose consumption in 14 middle-aged men with diabetes. Subjects followed an ambulatory high-fiber high-carbohydrate control diet at home for 8 wk, entered the hospital for 5 days on this diet, and spent the next 7 days on a similar diet supplemented with 50-60 g fructose. They continued the fructose diet at home for 23 wk, then resumed a postcontrol diet for an additional 16 wk. In the hospital, glycemic control improved significantly on the fructose-supplemented diet compared with the hospital control diet. In the ambulatory setting, no significant differences in plasma glucose, glycohemoglobin, serum cholesterol, triglycerides, lactate, or urate occurred between precontrol, fructose, or postcontrol periods. Fasting serum lactate was higher by 0.5 meq/L during the ambulatory fructose period than during the precontrol period. Body weight also increased during the ambulatory fructose period due to higher calorie intake. Adherence to fructose consumption was excellent and improved adherence to carbohydrate and fat recommendations. If total calorie intake is controlled to promote desirable body weight, crystalline fructose used with a high-carbohydrate high-fiber low-fat diet appears to be safe and acceptable for diabetic individuals.

Adherence to high-carbohydrate, high-fiber diets: long-term studies of non-obese diabetic men.

High-carbohydrate, high-fiber (HCF) diets provide short-term benefits for selected individuals with diabetes. Long-term effects of HCF diets, however, have not previously been documented. The effectiveness and acceptability of HCF diets for 14 men with diabetes followed for 4 years as outpatients were assessed. Hospital HCF diets with 70% of energy as carbohydrate and 65 gm plant fiber daily lowered insulin doses, serum cholesterol, and triglycerides. Home HCF diets with 55% to 60% carbohydrate and 50 gm plant fiber daily sustained improvements throughout the observed period of up to 86 months. Of the 11 patients for whom diet adherence was evaluated, 9 had good to excellent adherence, 1 had fair adherence, and 1 had poor adherence.

Hypocholesterolemic effects of oat-bran or bean intake for hypercholesterolemic men.

Oat or bean products, rich in water-soluble fiber, have distinct hypocholesterolemic effects in humans. After a control diet, 20 hypercholesterolemic men were randomly allocated to oat-bran or bean supplemented diets for 21 days on a metabolic ward. Control and test diets provided equivalent energy, fat, and cholesterol but test diets had twice more total and 3-fold more soluble fiber. Oat-bran diets decreased serum cholesterol concentrations by 19% (p less than 0.0005) and calculated low-density lipoprotein cholesterol by 23% (p less than 0.0025). Bean diets decreased serum cholesterol concentrations by 19% (p less than 0.0005) and low-density lipoprotein cholesterol by 24% (p less than 0.0005). Oat-bran increased fecal weight by 43% but beans did not. While oat-bran increased fecal bile acid excretion, beans had the opposite effect. Oat-bran or bean supplements may have an important role in nutritional management of selected hypercholesterolemic patients.