Diagnosis and management of patients with enhanced myometrial vascularity associated with retained products of conception.

OBJECTIVES: To assess the complication rate, including estimated amount of blood loss, in patients undergoing dilation and curettage (D&C) for the treatment of retained products of conception with markedly enhanced myometrial vascularity mimicking arteriovenous malformation. METHODS: This was a retrospective medical-records review study of patients with retained products of conception with enhanced myometrial vascularity presenting to our ultrasound unit between August 2015 and August 2017. Color/power Doppler imaging was used subjectively to identify the degree and extent of vascularity. All patients underwent D&C, and their operative reports and medical records were reviewed to see if ultrasound guidance was used, to ascertain estimated blood loss and to identify complications during or after the procedure. RESULTS: The study group included 31 patients, of whom seven had retained products of conception after a vaginal delivery and 24 had retained products of conception after a first-trimester termination or miscarriage. The largest dimension of the region of enhanced myometrial vascularity ranged from 10 mm to 53 mm, with 14/31 having a width of ≥ 20 mm. Fifteen patients underwent a standard D&C procedure, 13 an ultrasound-guided procedure and three hysteroscopy. Estimated operative blood loss varied from negligible to a maximum of 400 mL. There were no intraoperative complications, although one patient was treated for presumed endometritis. CONCLUSIONS: An increasing number of studies describe the enhanced myometrial vascularity associated with retained products of conception as 'acquired arteriovenous malformation', with some recommending management with uterine-artery embolization. Our study demonstrates that the enhanced myometrial vascularity is associated with retained products of conception, and surgical removal by D&C, possibly with the aid of ultrasound guidance or hysteroscopy, is a safe treatment option. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Right heart thrombus: recognition, diagnosis and management.

The clinical, echocardiographic, hemodynamic, angiographic and pathologic features of five patients who had right heart thrombus are presented and their management is discussed. Two modes of presentation were recognized. In four patients, right heart thrombus complicated peripheral venous thrombosis and was associated with major pulmonary thromboembolism and right heart obstruction. In the fifth, it complicated myocarditis with heart failure and appeared to cause right heart obstruction. Two-dimensional echocardiography was diagnostic of right heart thrombus in four patients and showed evidence of right heart dysfunction in those with major pulmonary thromboembolism. The diagnosis was confirmed at surgery in three patients and at autopsy in one. Three patients successfully underwent surgical removal of the thrombus followed by anticoagulation. One patient was treated successfully with anticoagulation alone. The only death occurred in the patient with myocarditis.

Tidal peritoneal dialysis to achieve comfort in chronic peritoneal dialysis patients.

Patients with end-stage renal disease on chronic peritoneal dialysis (CPD) can usually tolerate continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD) without abdominal discomfort or pain. In some patients, pain or discomfort occurs with complete drain of the peritoneal dialysis solution or upon initiation of dialysis filling when the peritoneal cavity is empty. We report on the use of tidal peritoneal dialysis (TPD) as a modality to alleviate this pain. Of 136 patients in our CPD unit, 18 (13%) were complaining of pain with complete drain or upon instillation of PD fluid. All were placed on TPD after other causes for abdominal pain were excluded. Six patients were placed on 25% TPD, and 12 patients on 50% TPD. The mean Kt/V of the patients on TPD was 2.46 +/- 0.68. With TPD, all patients had complete relief of abdominal discomfort. Patients who develop abdominal pain with complete drain or fill when the abdominal cavity is empty would benefit from TPD and be able to continue with CPD.

The fellow eye in retinal detachment: findings from the Scottish Retinal Detachment Study.

AIM: To characterise the predisposing pathology and clinical features in the fellow eyes of patients recruited as part of the Scottish Retinal Detachment Study. METHODS: The Scottish Retinal Detachment Study was a 2-year prospectively recruited population-based epidemiology study that sought to recruit all incident cases of primary rhegmatogenous retinal detachment (RRD) in Scotland. RESULTS: A total of 1202 incident cases of primary RRD were recruited in Scotland, over a 2-year period and in 94% (1130 cases) detailed data on the clinical features of fellow eyes with RRD were available. Full-thickness retinal breaks were found in 8.4% (95/1130) of fellow eyes on presentation. Lattice degeneration was present in 14.5% (164/1130) of fellow eyes. Thirteen per cent (148/1130) of affected fellow eyes had a best corrected visual acuity of 6/18 or worse with previous RRD, the second most common cause of poor vision. Overall, 7.3% (88/1202) of cases had RRD in both eyes; 60% of cases with consecutive bilateral RRD presented before the macula were affected. CONCLUSIONS: Rhegmatogenous pathology in the fellow eye represents an important threat to vision. Fellow-eye detachments are more common in pseudophakic individuals and those with a more myopic refractive error. Fellow-eye RRD has a greater likelihood of prompt presentation.

Mineralocorticoid and glucocorticoid status in idiopathic haemochromatosis.

OBJECTIVE: A number of studies have suggested that both primary (Addison's disease) and secondary adrenal failure may be caused by idiopathic haemochromatosis. There is little information on mineralocorticoid secretion. We have assessed the mineralocorticoid and glucocorticoid status of patients with idiopathic haemochromatosis. DESIGN: Cross-sectional study. PATIENTS: Eighteen males and one female with confirmed idiopathic haemochromatosis were investigated. Seven of the subjects had hepatic cirrhosis and three had hypogonadotrophic hypogonadism. MEASUREMENTS: A short Synacthen (tetracosactrin) test was undertaken in addition to an overnight metyrapone test and an insulin stress test. In addition, plasma aldosterone (PA) and plasma renin activity (PRA) were measured in a group of patients in the basal state and again in the upright position. RESULTS: The short Synacthen test, overnight metyrapone test and insulin stress test were normal in all subjects. The PA, PRA, and PA/PRA ratios in the upright position were not significantly different in the patients with idiopathic haemochromatosis compared to control subjects. CONCLUSION: In this patient population, no abnormality of either the pituitary adrenal axis or mineralocorticoid status was detected. Adrenocortical dysfunction is likely to be exceptionally rare in idiopathic haemochromatosis.

Tidal peritoneal dialysis: comparison of different tidal regimens and automated peritoneal dialysis.

BACKGROUND: The National Kidney Foundation Dialysis Outcomes Quality Initiative (DOQI) clinical practice guidelines have suggested minimal weekly Kt/V urea and creatinine clearance goals for peritoneal dialysis patients maintained on continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD). Achieving these goals may present problems, particularly in larger patients whose residual renal function declines. Thus, modifications of the dialysis regimen, such as tidal peritoneal dialysis (TPD), have been developed. However, the ability of TPD to improve the efficiency of the dialysis procedure remains uncertain. METHODS: Stable, cycling peritoneal dialysis patients were placed into two groups to study the effectiveness of different TPD prescriptions on peritoneal clearances of urea and creatinine. The volume of dialysis solution used and the duration of therapy were fixed in the two groups. Comparisons were made to conventional APD using multiple hourly cycles in which spent dialysis solution was completely drained with each cycle. Group I patients received a total of 15 L of PD solution over 9.5 hours in the dialysis unit. These patients received 10, 25, and 50% TPD and APD on four separate days. Group II patients received 24 L of PD solution over 9.5 hours. These patients received 25 and 50% APD on separate days in the dialysis unit. Peritoneal dialysis clearances for urea (pKt/V) and creatinine (pCCr) levels were calculated for both groups. The results were then analyzed to determine whether there was any significant difference among the various prescriptions. RESULTS: The data in the group I patients indicated a mean daily pKt/V of 0.22 +/- 0.03 with 10% TPD, 0.23 +/- 0.02 with 25% TPD, 0.25 +/- 0.02 with 50% TPD, and 0.26 +/- 0.02 with APD. Paired t-test analysis for pKt/V demonstrated that 10 and 25% TPD resulted in significantly lower values than 50% TPD and APD (P < 0.05). Mean daily pCCr L/24 h/1.73 m2 was 6.03 +/- 0.72 for 10% TPD, 6.34 +/- 0.83 for 25% TPD, 6.65 +/- 0.51 for 50% TPD, and 7.01 +/- 0.96 for APD; these differences were not significantly different. The data in the group II patients demonstrated a mean daily pKt/V of 0.28 +/- 0.03 with 25% TPD, 0.29 +/- 0.05 with 50% TPD, and 0.30 +/- 0.05 for APD. The mean daily pCCr was 6.69 +/- 0.47 for 25% TPD, 8.09 +/- 1.30 for 50% TPD, and 7.63 +/- 1.13 for APD. There were no statistical differences for pKt/V and pCCr within the 24 L group. CONCLUSION: When the duration of therapy and volume of dialysate volume are kept constant, TPD does not result in an improvement in clearances compared with conventional APD, at least with dialysate volumes up to 24 L.

Carotid sinus hypersensitivity in elderly nursing home patients.

Fourteen of 100 geriatric nursing home patients were shown to have evidence of carotid sinus hypersensitivity. The incidence of syncope and falls was noted in prospective follow-up over 33 months. Falls were classified as either simple or complicated by laceration or fracture. Patients experienced simple falls at similar rates whether carotid sinus hypersensitivity was present or absent. For patients with carotid sinus hypersensitivity, the risk of a laceration was increased more than twofold, that of fracture more than threefold, and that of syncope tenfold. Carotid sinus hypersensitivity warrants greater attention as a contributory factor to serious falls and syncope in the elderly; and its importance may have been underestimated in the past.

The effect of diazepam on induction of anesthesia with alfentanil.

This study investigated the effect of intravenous diazepam on induction of anesthesia with alfentanil. Forty ASA physical status I and II patients were given one of four treatments: alfentanil 100 micrograms/kg or 200 micrograms/kg, without diazepam or preceded by 0.125 mg/kg diazepam intravenously. Blood pressure, heart rate, respiration, response to verbal command, and movement were assessed for 5 min, and blood was taken for measurement of histamine, epinephrine, and norepinephrine. All ten patients receiving 100 micrograms/kg and five of the ten patients receiving 200 micrograms/kg of alfentanil responded to voice after 5 min, but only one in each group responded when it was preceded by diazepam. There was no rigidity or serious arrhythmias in any patient. Heart rate increased in patients receiving alfentanil alone. Blood pressure increased in those receiving 100 micrograms/kg but not 200 micrograms/kg. In patients given diazepam, tachycardia did not occur, but blood pressure decreased after administration of alfentanil. There were no significant changes in plasma levels of histamine or catecholamines. Five of the six cases of inadequate postoperative ventilation were in patients given diazepam. Despite these effects, diazepam or some other hypnotic agent may be indicated when alfentanil is used for induction.

Clinical results and quality of life after percutaneous transluminal coronary angioplasty: a preliminary report.

To evaluate the effect of percutaneous transluminal coronary angioplasty (PTCA) on quality of life, data on symptomatic status, functional capacity, life satisfaction, and psychological wellness were collected on 102 patients at 1 day pre-PTCA and 2 months post-PTCA, and on the first 50 of these patients at 10 months post-PTCA. There were highly significant changes (p < 0.001) in all quality of life measures between pre-PTCA and the 1st follow-up measurements. No further significant changes occurred in these measures between the 1st and 2nd follow-up measurements, indicating that the initial improvement in quality of life was sustained over this period. Data on primary success rate, complications, and pre- and post-PTCA risk factor scores are also reported.