[Outcomes of catheter ablation of atrial fibrillation in patients over 65 years of age]. / Výsledky katetrové ablace fibrilace síní u pacientu nad 65 let.

PURPOSE: This study assessed ablation techniques, recurrent arrhythmias, long-term outcomes, and complications of catheter ablation for atrial fibrillation (AF) in patients 65 years of age. METHODS: Consecutive patients aged < 65 years (n = 653) vs 65 years (n = 213), who underwent catheter ablation of AF in the course of eight years, were compared. Ablation strategy and procedure endpoints were left at the operators discretion. RESULTS: The group of patients 65 years comprised more females (p < 0.001), and more frequently presented with persistent AF (p = 0.010). These patients less frequently underwent simple pulmonary vein isolation (p = 0.017); on the contrary, extensive ablation including coronary sinus intervention was more common (p = 0.020). There was no difference in repeat ablation procedures (25 % vs 26 % patients; p = 0.823, or 1.4 vs 1.5 ablation procedures/1 patients; p = 0.479, respectively). Spectrum of recurrent arrhythmias did not differ between the groups except for more frequent paroxysmal AF before the first repeat ablation in patients < 65 years (p = 0.050). At the end of 49 ± 26 month total follow-up, stable sinus rhythm (SR) was achieved in 85 % patients < 65 years vs 76 % patients 65 years (p = 0.318). To maintain stable SR, older patients more often continued to take antiarrhythmic medication (p = 0.054). More serious complication occurred in 3.8 % of the patients 65 years vs 2.1 % of the patients < 65 years of age (p = 0.207). CONCLUSION: Patients 65 years of age achieved insignificantly worse long-term outcome after insignificantly fewer repeat ablation procedures, and with more frequent use of antiarrhythmic drugs. SR maintenance and risk of complications were, however, favorable.

[Catheter ablation of atrio-ventricular accessory pathways in the era of ablation therapy of complex arrhythmias: a changing perspective for oncoming generation of electrophysiologists]. / Katetrová ablace atrioventrikulárních prídatných drah v ére ablacní lécby komplexních arytmií: menící se perspektiva pro nastupující generaci elektrofyziologu

INTRODUCTION: Catheter ablation of atrio-ventricular accessory pathways has become a routine treatment method. However, its perspective has been changing in the era of ablation of complex arrhythmias. This study was aimed at evaluating accessory pathways ablation efficacy within the last nine years at one center. METHODS: From February 2002 to June 2011, catheter ablation of accessory pathways was performed in 247 patients (100 females, 42 ± 16 years). Elimination of accessory pathways conduction in both directions was the procedure endpoint. RESULTS: Immediate accessory pathways conduction elimination at the first ablation was achieved in 228 (92%) patients. Ablation failed to eliminate accessory pathways conduction in 19 (8%) patients, or accessory pathways conduction subsequently recurred in another 7 (3%) patients. Repeat ablation was completed in 20 (8%) patients, 2 patients underwent a third ablation procedure. In total, accessory pathway was permanently eliminated in 238 (96%) patients. Ablation failure was connected with a risky position in the vicinity of atrio-ventricular conduction system in 6 (67 %) out of 9 patients. By the individual A, B, C, D operators experience, efficacy of the first procedure/total efficacy, was 97%/99%, 90%/96%, 87%/87%, and 91%/91%, respectively (comparison of inter-operator efficacy of the first and repeat ablation by Kruskal-Wallis ANOVA test: p = 0,19 and 0,05, respectively). CONCLUSION: Accessory pathways ablation efficacy exceeds 95%, and ablation failure is dominantly related to the accessory pathways location close to the atrio-ventricular conduction system. Individual operator's experience was associated with a certain disparity between high and nearly absolute accessory pathways ablation efficacy.

[A comparison of two methods of long-term external ECG telemonitoring in patients after ablation for atrial fibrillation]. / Srovnání dvou metod dlouhodobého externího telemonitorování EKG po ablaci fibrilace síní

AIM: The aim of the study was to compare two methods of long-term ECG monitoring after atrial fibrillation (AF) ablation. METHODS: The study included 279 patients with paroxysmal (n = 163) or persistent (n = 116) AF, who were followed up for 1 year after the first catheter ablation for AF. All patients were provided with episodic ECG recorder for 1 year and instructed to send at least 2 random ECG recordings per day and whenever they sensed symptoms. They were also provided with external loop recorder for 2-3 weeks at 6 and 12 months to enable more continuous ECG monitoring. RESULTS: At the end of 39 ± 12 (12-60) month follow-up, 143 (88%) patients with paroxysmal AF, and 105 (91%) patients with persistent AF, respectively, remained in stable sinus rhythm. The efficacy of episodic recorder expressed as a ratio of patients with identified AF/atrial tachycardia (AT) out of all patients with a documented episode of AF/AT was superior to the efficacy of loop recorder. No AF/AT episode was recorded with the loop recorder that was not also documented by the episodic recorder. Of the patients with the AF/AT recurrence detected by the episodic recorder, the arrhythmia was also revealed by the loop recorder in 70% of the patients after paroxysmal AF ablation (p < 0.001), and in 52% of the patients after persistent AF ablation (p = 0.006). Asymptomatic AF/AT was present in 42 (26%) of patients with paroxysmal AF, and in 28 (24%) patients with persistent AF (p = 0.810). From conventional follow-up unexpected and clinically significant episode of AF/AT that required change in therapy was detected in 9 (5.5%) patients after ablation for paroxysmal AF, and in 4 (3.4%) patients after ablation for persistent FS. CONCLUSION: More episodes of AF/AT after ablation were detected by 1-year daily ECG monitoring using episodic recorder as compared to periodic ECG monitoring with loop recorder. Identification of clinically significant episodes of AF/AT unrecognized from conventional follow-up was low.

Evidence for immunoglobulin Fc receptor-mediated prostaglandin2 and platelet-activating factor formation by cultured rat mesangial cells.

The possibility of Fc-dependent uptake of IgG immune complexes was examined in subcultured rat mesangial cells free of monocytes. 195Au-labeled colloidal gold particles were coated either with BSA only or with BSA followed by rabbit anti-BSA-IgG or the F(ab')2 fragment of the IgG. Mesangial cells preferentially took up 195Au particles covered with BSA-anti-BSA-IgG over those covered with BSA or the F(ab')2 fragment. This uptake was a time-dependent and saturable process inhibitable by sodium azide or cytochalasin B. Using phase-contrast microscopy in the light reflectance mode, it was established that essentially all mesangial cells took up IgG-coated gold particles. By electron microscopy the process was shown to consist of vesicular uptake with delivery to endosomes. Mesangial binding-uptake of the IgG-covered particles was associated with stimulation of PGE2 synthesis and production of platelet-activating factor, a lipid mediator of inflammation. To characterize the potential Fc receptor for IgG we used the rosetting technique with sheep red blood cells coated with IgG subclass-specific mouse monoclonal antibodies. 50% of mesangial cells exhibited rosetting with red cells coated with mouse IgG2a, whereas negligible rosetting was observed with IgG2b or IgG1. Competition experiments confirmed the specificity of IgG2a binding. We conclude that cultured rat mesangial cells exhibit specific receptors for IgG and that occupancy of Fc receptors results in endocytosis and is associated with generation of PGE2 and platelet-activating factor. These observations may be of significance for immune-mediated glomerular diseases.

[Long term effectiveness of surgical cryoablation for chronic atrial fibrillation in patients undergoing surgery for severe mitral valve regurgitation]. / Dlouhodobá úcinnost chirurgické kryoablace chronické fibrilace síní provedené pri operaci pro závaznou mitrální regurgitaci.

OBJECTIVE: The objective of the study was to evaluate effectiveness of surgical cryoMAZE ablation for chronic atrial fibrillation (AF) in patients undergoing mitral valve surgical intervention. METHODOLOGY: Forty-seven patients (31 females), aged 67.3 +/- 7.3 years who underwent surgical intervention for severe mitral regurgitation were studied. Mitral valvuloplasty was performed in 21 patients, and mitral valve replacement in 26 patients. Combined procedure was employed in 35 patients; simultaneous aortocoronary bypass was performed in 16 patients, tricuspid valvuloplasty (TVP) in 5 patients, and aortic valve replacement (AVR) in 5 patients. RESULTS: The mean follow-up time was 19 +/- 10 months. After 6 or 12 months 36 or 32 patients were seen and 23 (64%) or 22 (69%) of them were in stable sinus rhythm (SR), respectively. In the subset of 24 patients with simultaneous intervention on a different valve (TVP or AVR), after 6 or 12 months, 14 (74 %) or 15 (83 %) patients had stable SR, respectively. In the follow-up period, 2 patients underwent successful catheter ablation for type I atrial flutter or for a residual left atrial atypical flutter. CONCLUSION: In the study using the method of cryoMAZE ablation for chronic AF performed during the mitral valve surgical intervention, a long-term stable SR was achieved in a high proportion of patients, particularly in patients with simultaneous intervention on two or three different valves.

[Catheter ablation of chronic atrial fibrillation using circumferential and complex linear lesions in the left atrium: modes of arrhythmia termination and long-term clinical outcome]. / Katetrová ablace pro chronickou fibrilaci síní metodou obkruzujících a komplexních lineárních lézí v levé srdecní síni. Ukoncení arytmie pri ablaci a dlouhodobé klinické výsledky.

OBJECTIVE: The aim of the article is to present the method and results of catheter ablation for chronic atrial fibrillation. METHOD: Catheter ablation for chronic atrial fibrillation was performed in 82 patients (18 females, aged 54 +/- 10 years), in 112 ablation procedures. Mean duration of the chronic phase of atrial fibrillation was 28 +/- 28 months. Before ablation, amiodarone was administered without effect to 74 (90%) patients, and was counter-indicated in 8 (10%) patients. Ablation strategy consisted of circumferential lesions around the pulmonary veins and of complex linear lesions in the left atrium. Full pulmonary vein antra isolation, and sinus rhythm restoration, or at least converting atrial fibrillation into the left atrial tachycardia, were the procedure end points. RESULTS: Sinus rhythm was restored by ablation at least in one of the ablation procedures in 43 (52%) patients. During the follow-up period spanning 17.3 +/- 11.6 months after the last ablation, stable sinus rhythm was achieved in 63 (77%) patients, of whom 38 (60%) had their sinus rhythm restored by ablation and another 14 (22%) their atrial fibrillation converted into the left atrial tachycardia. Of the 63 patients with stable sinus rhythm, class I or III antiarrhythmic medication has been maintained in 21 (33%) patients, and amiodarone has been taken by 13 (21%) patients. CONCLUSION: Catheter ablation of chronic atrial fibrillation is potentially highly effective in long-term restoration of sinus rhythm.

[Recurrent arrhythmias after catheter ablation of originally paroxysmal atrial fibrillation and results of repeat ablation]. / Recidivující arytmie po katetrové ablaci puvodne paroxyzmální fibrilace síní a výsledky opakované ablace.

AIMS: The aim is a description of the recurrent arrhythmias after previous ablation of paroxysmal atrial fibrillation (AF), and the results of a repeat catheter ablation. METHODS: A repeat ablation was performed in 76 patients (18 females, 54 +/- 11 years) in 96 procedures, which was 21% out of 362 patients, who had undergone the first ablation for a paroxysmal AF. The endpoints of the repeat ablation were re-isolation of the pulmonary veins (PV) and termination of a spontaneous or induced arrhythmia and restoration of a stable sinus rhythm (SR), and possibly achievement of noninducibility of any arrhythmia. RESULTS: Clinical left atrial tachycardia (LAT) was present in 10 (13%) patients before the first, and in 5 (25%) patients before the second repeat ablation. Arrhythmia arising from an arrhythmogenic PV due to the conduction recovery into the left atrium (LA) was found in 50 (66%) patients during the first, and in 7 (35%) patients during the second repeat ablation. Arrhythmias, predominantly of the reentry mechanism and originating in the LA free wall, were found in 26 (34%), respectively 13 (65%) during the first or the second repeat ablation. All arrhythmias from PVs were terminated by a PV encircling ablation. Substrate-related arrhythmias were terminated by ablation except for 2 (3%) patients during the first and 3 (15%) patients during the second repeat ablation. Persistent AF was mainly terminated via conversion into a LAT. In these cases, the ablation sites leading to the SR restoration were, similarly to the primary LATs, located predominantly in the LA anterior wall. During the 22 +/- 13 months follow-up, 68 (89%) patients were free of AF, 54 (71%) patients off the antiarrhythmic drugs and 14 (18%) patients with the class I or III antiarrhythmic drugs. CONCLUSION: AF associated with PV-LA re-connection dominated prior to the first repeat ablation, then the proportion of the substrate-related arrhythmias from the LA free wall increased. Clinical efficacy of the repeat ablation is high.

TAK-228 (formerly MLN0128), an investigational dual TORC1/2 inhibitor plus paclitaxel, with/without trastuzumab, in patients with advanced solid malignancies.

PURPOSE: This phase I trial evaluated the safety, pharmacokinetic profile, and antitumor activity of investigational oral TORC1/2 inhibitor TAK-228 plus paclitaxel, with/without trastuzumab, in patients with advanced solid malignancies. METHODS: Sixty-seven patients received TAK-228 6-40 mg via three dosing schedules; once daily for 3 days (QDx3d QW) or 5 days per week (QDx5d QW), and once weekly (QW) plus paclitaxel 80 mg/m2 (dose-escalation phase, n = 47) and with/without trastuzumab 2 mg/kg (expansion phase, n = 20). Doses were escalated using a modified 3 + 3 design, based upon dose-limiting toxicities in cycle 1. RESULTS: TAK-228 pharmacokinetics exhibited dose-dependent increase in exposure when dosed with paclitaxel and no apparent differences when administered with or 24 h after paclitaxel. Dose-limiting toxicities were dehydration, diarrhea, stomatitis, fatigue, rash, thrombocytopenia, neutropenia, leukopenia, and nausea. The maximum tolerated dose of TAK-228 was determined as 10-mg QDx3d QW; the expansion phase proceeded with 8-mg QDx3d QW. Overall, the most common grade ≥3 drug-related toxicities were neutropenia (21%), diarrhea (12%), and hyperglycemia (12%). Of 54 response-evaluable patients, eight achieved partial response and six had stable disease lasting ≥6 months. CONCLUSION: TAK-228 demonstrated a safety profile consistent with other TORC inhibitors and promising preliminary antitumor activity in a range of tumor types; no meaningful difference was noted in the pharmacokinetics of TAK-228 when administered with or 24 h after paclitaxel. These findings support further investigation of TAK-228 in combination with other agents including paclitaxel, with/without trastuzumab, in patients with advanced solid tumors. CLINICALTRIALS. GOV IDENTIFIER: NCT01351350.

[Sustained monomorphic ventricular tachycardia in patients with structural heart disease. Different arrhythmogenic substrates, different options of palliative and curative treatment in the era of three-dimensional mapping]. / Setrvalá monomorfní komorová tachykardie u patientu se strukturalnim postizenim srdce. Ruzné arytmogenní substráty, ruzné moznosti paliativní nebo kurativní lécby katetrovou ablací v ere trojrozmerného mapování.

UNLABELLED: Results of catheter ablation of sustained monomorphic ventricular tachycardia (SMVT) in patients with structural heart disease are presented. METHODS: Catheter ablation was performed in 34 patients (5 females), aged 63 +/- 11 years. One (3%) patient had a permanent SMVT resistant to electric cardioversion, 13 (38%) patients had incessant SMVT, 4 (12%) patients had SMVT at least once a day, 9 (26%) patients at least once a week, and 7 (21%) patients at least once a month. Twenty-nine (85%) patients were treated with amiodarone. Twenty-seven (79%) patients had a history of remote myocardial infarction, 2 (6%) patients presented with dilated cardimyopathy, 4 (12%) patients had arrhythmogenic right ventricular cardimyopathy, and 1 (3%) patient was after surgery for tetralogy of Fallot. Left ventricular ejection fraction was 35 +/- 13%. Ablation was mostly performed as a palliative approach with the purpose to eliminate clinically significant forms of SMVT leading to frequent ICD discharges, respectively to the worsening of heart failure. Less frequently, ablation was accomplished as a curative therapy. For the SMVT ablation, electroanatomic mapping was used, and, target or substrate mapping and ablation or their combinations were employed. RESULTS: Clinical form of SMVT was successfully eliminated in 33 (97%) patients, all inducible ventricular tachyarrhythmias were eliminated in 14 (41%) patients. Any ventricular tachycardia did not recur in 29 (85%) patients during 22 +/- 17 months follow-up. Twenty-three (68 %) patients had eventually implanted ICD. Ablation was performed as a curative procedure in 11 (32 %) patients. Average procedure duration was 213 +/- 56 minutes, fluoroscopy time was 18 +/- 9 minutes, and number of radiofrequency applications was 23 +/- 13. CONCLUSION: Catheter ablation in patients with structural heart disease offers a highly effective method in elimination of clinical forms of SMVT. In long-term perspective, it is associated with low recurrence of any ventricular tachyarrhythmia. Efficacy of the ablation in elimination of all inducible forms of ventricular tachyarrhythmia is lower and therefore it should be mostly viewed as a palliative method, particularly in patients with left ventricular dysfunction and incomplete revascularization.

[Idiopathic premature ventricular complexes--catheter ablation as a therapeutic alternative]. / Idiopatická komorová extrasystolie--katetrová ablace jako lécebná alternativa.

UNLABELLED: Frequent isolated ventricular premature complexes (VPCs) in patients without major structural heart disease are generally associated with benign prognosis, however can lead to serious symptoms and also to the development of left ventricular dysfunction. Purpose of this study is to present mapping findings and immediate results of catheter ablation of frequent idiopathic VPCs, and evaluation of long-term clinical outcome and the role of catheter ablation in clinical practice. METHODS: Twenty-seven patients, aged 48 +/- 14 years without major structural heart disease, presenting with frequent VPCs, were investigated electrophysiologically in 28 procedures. Twenty-five patients underwent catheter ablation. RESULTS: In 19 patients, the ectopic focus was found in the right ventricular outflow tract (RVOT) and could be reached from the endocardial approach. In these patients, VPCs were successfully eliminated by the ablation. Comparison of 24-hour Holter ECG recordings showed complete elimination of the target VPCs in all the cases [18,483 +/- 12,790 (2,152-48,820)/17 +/- 10 (3-42) % VPCs before ablation vs. 94 +/- 219 (0-763)/0.01 +/- 0.2 (0-0.7) % VPCs after ablation]. In 5 patients, mapping revealed epicardial localization of the ectopic focus in the OT. Ablation endocardially from the RVOT failed in 2 of the patients, cryoablation epicardially from the venous system was partially successful in 1 patient, and no ablation was attempted in 2 patients. In another 3 patients, ectopic foci were found in other parts of the ventricles and ablation was completely successful in one case. During the 14 +/- 9 (1-34) month follow-up period, full elimination of the target VPCs and elimination or significant reduction of symptoms was achieved in 20 (74%) patients. The procedures were accomplished without complications and with fluoroscopy time of 8,2 +/- 5,9 minutes. CONCLUSION: Catheter ablation of frequent idiopathic VPCs was performed effectively and safely, particularly, if the ectopic focus was localized on the endocardial aspect of the RVOT. Efficacy of catheter ablation ofVPCs arising from the epicardium of ventricular OT or other atypical sites is limited by inaccessibility or proximity to the conduction system. Indication to more aggressive mapping and ablation methods like intrapericardial approach or ablation from inside the venous system should be always critically considered with regard to the symptoms or other clinical risk factors.

A multicenter study of the efficacy and safety of sustained release GH in the treatment of naive pediatric patients with GH deficiency.

Treatment of naive children with GH deficiency has relied upon long-term replacement therapy with daily injections of GH. The daily schedule may be inconvenient for patients and their caregivers, possibly promoting nonadherence with the treatment regimen or premature termination of treatment. We studied a new sustained release GH formulation, administered once or twice monthly, to determine its efficacy and safety in this population. Seventy-four prepubertal patients with documented GH deficiency were randomized to receive sustained release recombinant human GH at either 1.5 mg/kg once monthly or 0.75 mg/kg twice monthly by sc injection in a 6-month open-label study. Efficacy was determined by growth data from 69 patients completing 6 months and 56 patients completing 12 months in an extension study. Growth rates were significantly increased over baseline and were similar for the two dosage groups. The mean (+/-SD) annualized growth rate (pooled data) was 8.4 +/- 2.1 cm/yr at 6 months, and the growth rate was 7.8 +/- 1.8 at 12 months compared with 4.5 +/- 2.3 at baseline. Standardized height, bone age, and predicted adult height assessments demonstrated catch-up growth without excessive skeletal maturation. Injection site-related events (including pain, erythema, and nodules) were the most commonly reported adverse events; no serious adverse events related to treatment were reported. Laboratory studies documented no accumulation of trough GH or IGF-I levels during treatment, nor did glucose intolerance or persistent hyperinsulinism develop. Sustained release recombinant human GH is safe and effective for long-term GH replacement in children with GH deficiency. Patients achieved similar growth velocities when sustained release GH was given once or twice monthly. The enhanced convenience of this dosage form may result in greater long-term adherence to the treatment regimen.

Hysteroscopic management of symptomatic submucous fibroids.

Twenty-eight patients who underwent resection of a submucous fibroid under hysteroscopic control are reported with a follow-up for one to seven years. Seven patients underwent subsequent hysterectomy for various reasons. Two required repeat hysteroscopic resection and 17 returned to normal menses without difficulty. Five of these patients subsequently had a total of eight pregnancies, with five living children. The implications of this option of therapy are discussed.

Evaluation and management of the pelvic mass: a review of 540 cases.

The management of 540 patients with the diagnoses of "pelvic mass/uterine leiomyomata" was reviewed with respect to preoperative evaluation, surgical procedures, and final pathologic diagnosis. Approximately 6170 patients were admitted to the Gynecology Service at St. Luke's-Roosevelt Hospital Center from July 1984 to June 1985. During this period, 36 of 432 diagnostic laparoscopies (8.3%) and 503 of 1666 laparotomies (30.2%) were performed to evaluate or treat these women. The final diagnoses in the 249 patients admitted with the impression of leiomyomata were: leiomyomata, 235 (94.4%); benign adnexal masses, seven (2.8%); cancers, four (1.6%); and miscellaneous, three (1.2%). Of the 291 patients evaluated for pelvic mass, the findings were: benign ovarian or tubal cysts, 98 (33.7%); leiomyomata, 42 (14.4%); cancers, 40 (13.7%); benign cystic teratomas, 38 (13.1%); endometriosis, 28 (9.6%); miscellaneous, 23 (7.9%); and pelvic inflammatory disease, 22 (7.6%). Correlation between the patient's age, preoperative impression, and final diagnosis is presented with particular attention to the 44 patients (8.1%) in whom malignancy was found. All the possibilities that such masses may represent must be considered preoperatively, and the patient be informed of her risk of malignancy.

The long-term effectiveness of hysteroscopic treatment of menorrhagia and leiomyomas.

One hundred fifty-six of 177 patients admitted to the St. Luke's/Roosevelt Hospital Center between November 1973 and November 1988 for hysteroscopic treatment of menorrhagia and/or uterine leiomyomas were followed for long-term complications and necessity for repeat surgery. Ninety-four patients underwent submucous resection alone and 62 patients underwent endometrial ablation with or without submucous resection. Among the submucous-resection group, 24.5% reported late postoperative problems and 15.9% underwent further surgery. After 9 years of followup, 83.9% of the patients had not required further surgery. Among the ablation group, 22.5% experienced recurrence of increased bleeding and 8.1% had another surgical procedure. After 6 years of follow-up, 91.3% of the patients had not required further surgery. Twenty-one patients became pregnant after submucous resection, with 18 infants delivered. No patients who underwent endometrial ablation became pregnant. This modality of treatment appears to be effective over the long term, although effectiveness appears to diminish with time.

The incidence of asymptomatic uterine anomalies in women undergoing transcervical tubal sterilization.

The incidence of congenital anomalies of the uterus has generally been obtained from studies of women undergoing evaluation for infertility, and has been reported as 1-10%. However, the true incidence of uterine malformations is not known. This study reviews hysterosalpingograms obtained for evaluation of tubal closure after transcervical sterilization in normal multiparous women using methylcyanoacrylate and the FEMCEPT device. Of the 840 hysterosalpingograms studied, 16 congenital uterine anomalies were identified, for an incidence of 1.9%. The presence of anomalies in this population of women may more closely represent the incidence of congenital uterine anomalies in the general population.

Symptomatic intrauterine retention of fetal bones.

Four patients with symptomatic intrauterine retention of fetal bones are discussed. Presenting complaints included infertility, irregular vaginal bleeding, vaginitis, and spontaneous passage of fetal bones. Two patients had uterine anomalies; 1 patient had a retained twin pregnancy. Pelvic ultrasound and x-ray films of the pelvic cavity are helpful in making a diagnosis. Hysteroscopy is invaluable both in confirming the diagnosis and in achieving successful removal of fetal bone.

Pregnancy rates after hysteroscopic polypectomy and myomectomy in infertile women.

OBJECTIVE: To compare reproductive benefits of hysteroscopic myomectomy and polypectomy for infertility to outcomes in infertile couples with normal hysteroscopic findings. METHODS: Women with diagnoses of infertility who had hysteroscopic evaluations by a single surgeon between 1975 and 1996 were sent a routine follow-up questionnaire regarding their reproductive histories. All 92 subjects who were located responded to the questionnaire, and 78 met inclusion criteria: age under 45 years, at least 12 months of infertility, and at least 18 months of follow-up with attempts to conceive, including in vitro fertilization in women with bilateral tubal occlusion. RESULTS: Of the 78 subjects, 36 had myomectomies, 23 had polypectomies, and 19 had normal cavities. Among the three groups, there were no significant differences in age, type of infertility, length of infertility, or follow-up after the procedure. Polypectomy subjects had significantly higher pregnancy and live birth rates than women with normal cavities. Women who had myomectomies larger than 2 cm had significantly higher pregnancy and live birth rates, achieving statistical significance at a myoma size of 3 cm or greater for live births. Spontaneous abortion rates among first pregnancies after myomectomy, polypectomy, or normal study were similar: 31.5%, 27.7%, and 37.5%, respectively. CONCLUSION: Both hysteroscopic polypectomy and hysteroscopic myomectomy appeared to enhance fertility compared with infertile women with normal cavities. Despite concern that hysteroscopic resection of a large myoma might ablate a large surface area of the endometrial cavity, the reproductive benefit appears greater than the risk.

Adenocarcinoma of the endometrium after endometrial ablation.

BACKGROUND: Endometrial ablation is a relatively new technique for treating abnormal uterine bleeding not associated with malignancy. Long-term outcome data after endometrial ablation are limited, and incidence of endometrial adenocarcinoma after ablation is unknown. CASE: A 55-year-old black woman who had endometrial ablation for abnormal uterine bleeding after excluding uterine cancer presented 5 years later with similar symptoms and a histologic diagnosis of well-differentiated adenocarcinoma of the uterus. She refused surgery and had radiation treatment for probable stage I endometrial adenocarcinoma. CONCLUSION: It is unlikely in this high-risk patient that the endometrial ablation masked an undetected malignancy or delayed the diagnosis. Given the interval, the adenocarcinoma might have occurred de novo.

Chemical induction of tubal blockade in the monkey.

PIP: The ability of the retrograde transtubal instillation of toxic agents to produce isthmic tubal occlusion was studied at laparotomy in 8 healthy, parous pigtail monkeys. The agents used were silver nitrate in 2 hydrophilic concentrations, hydrophilic ointment with 50% zinc chloride, and methyl alpha-cyanoacrylate with about 5% zinc chloride. An acute and chronic inflammatory response was observed to extend through about 33% of the isthmic tubal wall in all animals. Tubes treated with cyanoacrylate differed from the others in that a giant-cell reaction occurred around the agglomerated polymer. A gradual invasion of the tubal lumen by plump, active fibroblasts was evident at 5-7 weeks. Tubes instilled with silver nitrate showed the greatest rate of fibrosis. By 7 weeks, all treated tubes showed hematological evidence of closure. In other studies, repeated tubal injury by electrocoagulation or instillation of phenol, silastic, or quinacrine resulted in tubal occlusion. Experiments with tubal-occluding agents hold the prospect of developing occlusive agents that can be administered transcervically in humans.^ieng

Obstetric complications after treatment of intrauterine synechiae (Asherman's syndrome).

This review comprises 36 patients who were treated for Asherman's syndrome from 1968 to 1974 at the Sloane Hospital for Women. Of the 18 patients who later conceived only 6 had uncomplicated term deliveries. Four had premature deliveries resulting in neonatal death. Three had placenta accreta and postpartum hemorrhage, necessitating a cesarean hysterectomy in 1. Two patients required cesarean section for complications due to the syndrome, 2 had spontaneous abortion, and 1 had a cervical pregnancy requiring total hysterectomy. Only 10 babies survived. The incidence and severity of complications in conceptions following treatment for Asherman's syndrome is high, and the obstetrician must be prepared to manage them.