Carbon dioxide in office diagnostic hysteroscopy: An open question. A multicenter randomized trial on 1982 procedures.

OBJECTIVE: to compare carbon dioxide and saline solution distension in diagnostic hysteroscopies with regards to patient discomfort and procedural time and in accordance with the instrument diameter (5 mm vs 3.5 mm). The secondary outcome was to evaluate the role of the patient age and the obstetrical history on perception of pain and procedural time. STUDY DESIGN: This is a prospective multicenter randomized study including 1982 patients that underwent office diagnostic hysteroscopy in: Policlinico Abano Terme, Università Cattolica del Sacro Cuore in Rome and Ente Ecclesiastico Ospedale Generale Regionale "F. Miulli" in Acquaviva delle Fonti. They were firstly randomized according to distension medium and secondly according to instrument diameter. Pain perception after the procedure was assessed by VAS (Visual Analogue Scale) score and procedural time was registered. Mann-Whitney U test was used to compare data. RESULTS: Lower pain score and procedural time were recorded with the employment of Carbon Dioxide (p < 001). Patient discomfort and procedural time were significantly influenced by the instrument diameter independent of the distension medium used, though in the subgroup where gas was employed VAS score after 1 min (VAS1) resulted lower compared to saline solution in both the traditional and mini-hysteroscopy procedures (p < 001). CONCLUSION: Carbon dioxide and saline solution are both suitable distension media for outpatient diagnostic hysteroscopy; nonetheless, carbon dioxide confers advantages in terms of pain perception and procedural time.

Mandibular fracture: analysis of 293 patients treated in the Hospital of Clinics, Federal University of Uberlândia.

UNLABELLED: Mandibular fracture is the second most common facial fracture and there has been a significant increase in number of cases in the last years. Misidentification and inadequate treatment can take to permanent aesthetic or functional deformity. AIM: Evaluate cases of mandibular fracture reduction in the Hospital of Clinics of the Federal University of Uberlândia, from January of 1974 to December of 2002. STUDY DESIGN: Historical cohort. PATIENT AND METHOD: Two hundred and ninety-three cases of reduction of mandibular fractures were retrospectively analyzed according to factors related to: patient, trauma, signs and symptoms, and surgical treatment. RESULTS: There has been a clear tendency of increase of the number of mandibular fractures along the years. There was higher prevalence in male (4:1), with occurrence peak between 20 to 29 years old. The principal causes of fracture in this study were traffic accidents and violence, representing 72.4%. One hundred and thirty-five patients presented only one fracture. The most injured sites were, in decreasing order, symphysis, condyle, angle, body, ramus, and coronoid. We performed closed reduction (28), open reduction (213) and association of the two (11 patients); 56.8% of the patients were treated within the first 3 days; and, 50.4% were discharged from the hospital until the first postoperative day. About 10% of the patients presented complications, being osteomyelitis the most frequent one. CONCLUSION: The incidence of mandibular fractures was remarkably larger in the male sex, during the third decade of life. The most common cause was traffic accident, and symphysis and condyle were the most injured sites. Isolated fractures occurred in over half of the cases. Most of the patients were treated in the first three days and were discharged until the first postoperative visit. Closed reduction was the treatment most commonly employed. The most frequent complication was osteomyelitis.

Asymmetric optic nerve sheath diameter as an outcome factor following cranioplasty in patients harboring the 'syndrome of the trephined'.

UNLABELLED: Decompressive craniectomy (DC) is gaining an increasing role in the neurosurgical treatment of intractable intracranial hypertension, but not without complications. A rare complication is the "syndrome of the trephined" (ST). It occurs when the forces of gravity overwhelm intracranial pressures, leading the brain to become sunken. OBJECTIVE: To determine the usefulness of asymmetric optic nerve sheath diameter (ONSD) as an outcome factor after cranioplasty. METHOD: We followed-up 5 patients submitted to DC and diagnosed with ST. All were submitted to brain MRI to calculate the ONSD. RESULTS: Only two patients presented an asymmetric ONSD, being ONSD larger at the site of craniectomy. Surprisingly these patients had a marked neurological improvement after cranioplasty. They became independent a week after and statistically earlier than others. CONCLUSION: It is presumed that the presence of an asymmetric ONSD in trephined patients is an independent factor of good outcome after cranioplasty.

Gradenigo's Syndrome: Beyond the Classical Triad of Diplopia, Facial Pain and Otorrhea.

We report a case of a non-Hodgkin's lymphoma in a young woman presenting with an abdominal mass and an unusual instance of cranial nerve palsies mimicking Gradenigo's syndrome. This condition is characterized by a triad of otorrhea, facial pain and diplopia, related to otitis media in the pre-antibiotic era. Incomplete and atypical clinical features of Gradenigo's syndrome have been described and noninfectious causes may mimic this condition. Careful clinical history and physical examination, including neuroimaging, are necessary to make a differential diagnosis.

Hysteroscopic removal of gauze packing inadvertently sutured to the uterine cavity: report of 2 cases.

We report on 2 cases of successful hysteroscopic removal of uterovaginal packing, inserted during cesarean sections after uterine hemorrhage resistant to medical therapy. The packing, in both cases, could not be removed vaginally with sponge forceps because the packing had been sutured to the uterine cavity. A hysteroscopic approach enabled identification and cutting with 5F scissors of the stitches fixing the packing to the uterine walls, allowing straightforward removal in an outpatient setting and avoiding a repeated laparotomy. Some useful techniques to handle such a situation are described.

A new hysteroscopic technique for the preparation of partially intramural myomas in office setting (OPPIuM technique): A pilot study.

OBJECTIVE: To assess the safety and the effectiveness of a novel hysteroscopic technique for the Office Preparation of Partially Intramural Myomas (OPPIuM), to facilitate the subsequent, already scheduled, resectoscopic myomectomy. DESIGN: Pilot study. SETTING: University of Bari, Naples and Foggia. PATIENTS: Fifty-nine fertile women (age 27-48 years) diagnosed at office hysteroscopy as having symptomatic submucous myomas>1.5 cm with intramural development (G1 and G2), scheduled for resectoscopic surgery. INTERVENTIONS: The OPPIuM technique consisted of an incision of the endometrial mucosa covering the myoma by means of Fr scissors or bipolar Versapoint Twizzle electrode, along its reflection line on the uterine wall, up to the precise identification of the cleavage surface between the myoma and its pseudo-capsule. Such procedure was aimed at triggering the protrusion of the intramural portion of the myoma into the uterine cavity during the following menstrual cycles, thus facilitating the subsequent total removal of the lesion via resectoscopic surgery. All patients underwent follow-up in-patient hysteroscopy after 2 menstrual cycles before resectoscopic surgery were performed. MEASUREMENTS AND MAIN RESULTS: The OPPIuM technique was successfully performed in all cases. The mean diameter of successfully prepared myomas was 2.9+/-0.8 cm. At follow-up hysteroscopy, the conversion of partially intramural myomas into totally or prevalently intracavitary ones was observed in 93.2% (55/59) of cases. In 2 of 3 cases of failure, the myomas' size was>4 cm. One patient was excluded from the study because of the occurrence of total spontaneous expulsion of the myoma at the subsequent menstrual cycle. CONCLUSIONS: Our preliminary findings seem to support the safety and the effectiveness of the OPPIuM procedure by reporting the conversion of myomas with intramural development>1.5 cm into totally or prevalently intracavitary ones in nearly 93% of cases. Such technique may allow surgeons to perform resectoscopic surgery more safely and quickly as dealing with prevalently intracavitary lesions. However, further studies are mandatory to validate its use in daily practice.

Asymmetric optic nerve sheath diameter as an outcome factor following cranioplasty in patients harboring the 'syndrome of the trephined' / Assimetria do diametro da bainha do nervo optico como fator prognostico apos cranioplastia em pacientes portadores da 'sindrome do trefinado'

Decompressive craniectomy (DC) is gaining an increasing role in the neurosurgical treatment of intractable intracranial hypertension, but not without complications. A rare complication is the “syndrome of the trephined” (ST). It occurs when the forces of gravity overwhelm intracranial pressures, leading the brain to become sunken. Objective To determine the usefulness of asymmetric optic nerve sheath diameter (ONSD) as an outcome factor after cranioplasty. Method We followed-up 5 patients submitted to DC and diagnosed with ST. All were submitted to brain MRI to calculate the ONSD. Results Only two patients presented an asymmetric ONSD, being ONSD larger at the site of craniectomy. Surprisingly these patients had a marked neurological improvement after cranioplasty. They became independent a week after and statistically earlier than others. Conclusion It is presumed that the presence of an asymmetric ONSD in trephined patients is an independent factor of good outcome after cranioplasty. .

A craniectomia descompressiva (CD) tem papel fundamental no tratamento da hipertensão intracraniana refratária, mas não é isenta de complicações. Uma complicação rara é a “síndrome do trefinado” (ST). Ela ocorre quando as forças gravitacionais se sobrepõem à pressão intracraniana. Objetivo Determinar a utilidade do diâmetro da bainha do nervo óptico (DBNO) como fator prognóstico após cranioplastia. Método Foram acompanhados 5 pacientes trefinados portadores da ST. Estes pacientes foram submetidos à ressonância magnética com medida do diâmetro da bainha do nervo óptico (DBNO). Resultados Dois pacientes apresentaram uma assimetria do DBNO, sendo o diâmetro maior do lado craniectomizado. Para nossa surpresa estes evoluíram melhor do que os que apresentavam o DBNO simétrico. Estes pacientes se tornaram independentes uma semana após, e estatisticamente mais cedo do que os outros. Conclusão Há evidências de que a assimetria do DBNO sirva como fator de bom prognóstico após cranioplastia no pacientes portadores da ST. .

Office hysteroscopic metroplasty: three "diagnostic criteria" to differentiate between septate and bicornuate uteri.

STUDY OBJECTIVE: To evaluate the benefits of adopting 3 simple "diagnostic criteria" in the differential diagnosis between septate and bicornuate uteri, and the relative treatment by hysteroscopy in an office setting. DESIGN: Prospective clinical study (Canadian Task Force classification III). SETTING: University-affiliated hospital. PATIENTS: Two hundred-sixty patients with a hysteroscopic diagnosis of a double uterine cavity were enrolled. INTERVENTIONS: Office hysteroscopic metroplasty was performed without analgesia or anesthesia using 5F scissors. MEASUREMENTS AND MAIN RESULTS: The presence of vascularized tissue, sensitive innervation, and the appearance of the tissue at the incision of a supposed septum during an office hysteroscopic procedure were the criteria used to differentiate a septate from a bicornuate uterus. In 93.1% of the cases, office hysteroscopic metroplasty was successfully performed during the same diagnostic procedure. In 15 of 18 patients scheduled for laparoscopic control of the uterine anatomy, the suspicion of a bicornuate uterus was confirmed. Hysteroscopic follow-up at 3 months showed a regular uterine cavity with a fundal notch less than 1 cm. CONCLUSION: The study demonstrates the possibility of obtaining complete, safe removal of uterine septae in most cases by office hysteroscopy confirmation, using mechanical instruments, in an office setting. This was achieved by relating the diagnosis and treatment to simple anatomic and physiologic diagnostic criteria.

Hysteroscopy and menopause: past and future.

PURPOSE OF REVIEW: The main aim in investigating post-menopausal women is to exclude endometrial cancer. The purpose of this review is to define up-to-date clinical guidelines for the management of all post-menopausal women (asymptomatic as well as symptomatic). RECENT FINDINGS: Thanks to improvements in both the technology and the technique, hysteroscopy has become a simple and painless procedure that can easily be performed in an office or outpatient setting without any particular discomfort for the patient. The new, easier procedure, well tolerated by patients, has excellent diagnostic and surgical accuracy. Assuming that office hysteroscopy could offer a better visualization of the uterine cavity without increasing patient discomfort if compared to ultrasound, various authors have recently proposed the use of hysteroscopy as a first-line procedure in the approach to the menopausal patient. This could be defined as a change in strategy that has yielded very interesting results in terms of a better understanding of the appearance of the uterine cavity and the clinical value of small intra-cavitary pathologies (and their related treatment), particularly in asymptomatic women. SUMMARY: Hysteroscopy can be considered a routine outpatient method providing immediate results and causing minimal discomfort, especially when performed with the vaginoscopic approach. This technique has ushered in a new era of very-low-cost hysteroscopy, because only the hysteroscope is required in the outpatient procedure, with no need for additional instruments, medication, extra personnel or dedicated theatre. The time taken is comparable to that required for transvaginal sonography.

Assimetria do diâmetro da bainha do nervo óptico como fator prognóstico após cranioplastia em pacientes portadores da ‘Síndrome do Trefinado’ / Asymmetric optic nerve sheath diameter as an outcome fator following cranioplasty in ‘syndrome of the trephined’ patients

Introdução: A craniectomia descompressiva (CD) tem papel fundamental no tratamento da hipertensão intracraniana refratária,mas não é isenta de complicações. Uma complicação rara é a “Síndrome do Trefinado” (ST). Ela ocorre quando as forçasgravitacionais se sobrepõem à pressão intracraniana. Método: Foram acompanhados 5 pacientes trefinados portadores da ST.Estes pacientes foram submetidos à Ressonância Magnética com medida do diâmetro da bainha do nervo óptico (DBNO). Oobjetivo do estudo foi determinar a utilidade do DBNO como fator prognóstico após cranioplastia. Resultados: Dois pacientesapresentaram uma assimetria do DBNO, sendo o diâmetro maior do lado craniectomizado. Para nossa surpresa estes evoluírammelhor do que os que apresentavam o DBNO simétrico. Estes pacientes se tornaram independentes uma semana após, eestatisticamente mais cedo do que os outros. Conclusão: Há evidências de que a assimetria do DBNO sirva como fator de bomprognóstico após cranioplastia no pacientes portadores da ST.

Fratura de mandíbula: análise de 293 pacientes tratados no Hospital de Clínicas da Universidade Federal de Uberlândia / Mandibular fracture: analysis of 293 patients treated in the Hospital of Clinics, Federal University of Uberlândia

A fratura de mandíbula ocupa o segundo lugar entre as fraturas dos ossos da face, tendo havido aumento significativo de casos nos últimos anos. A não-identificação e o tratamento inadequado podem levar à deformidade estética ou funcional permanente. OBJETIVO: Avaliar os casos submetidos à redução de fratura de mandíbula no Hospital de Clínicas da Universidade Federal de Uberlândia, entre janeiro de 1974 e dezembro de 2002. FORMA DE ESTUDO: coorte historica. PACIENTES E MÉTODO: Duzentos e noventa e três pacientes foram submetidos à redução de fratura de mandíbula e retrospectivamente foram avaliados segundo fatores relacionados a: paciente, trauma, quadro clínico e tratamento cirúrgico. RESULTADOS: Houve uma clara tendência de aumento do número de fraturas de mandíbula ao longo dos anos. Houve um predomínio no sexo masculino (4:1), com pico de ocorrência entre 20 a 29 anos. As principais causas de fratura da mandíbula neste estudo foram acidentes de trânsito e violência, perfazendo juntas 72,4 por cento. Cento e trinta e cinco pacientes apresentavam fratura única. Os sítios mais acometidos foram, em ordem decrescente, sínfise, côndilo, ângulo, corpo, ramo e processo coronóide. Foram realizadas redução incruenta (28), cruenta (213) e associação das duas (11 pacientes), sendo que 56,8 por cento dos pacientes foram tratados nos primeiros 3 dias e 50,4 por cento recebeu a alta hospitalar até o primeiro pós-operatório. Cerca de 10 por cento dos pacientes apresentaram complicações, sendo osteomielite a mais freqüente. CONCLUSÃO: A incidência de fraturas de mandíbula foi marcadamente maior no sexo masculino, durante a terceira década de vida. A causa mais comum foi o acidente de trânsito e as regiões mais atingidas foram sínfise e côndilo. As fraturas isoladas de mandíbula ocorreram em mais de metade dos casos. A maioria dos pacientes foi tratada nos primeiros três dias e recebeu alta até o primeiro pós-operatório. A redução cruenta foi tratamento mais comumente empregado. A complicação mais freqüente foi a osteomielite.

Pericondrite do pavilhäo auricular em consequência de acupuntura / Auricular perichondritis Due to Acupunture

0s autores apresentam o caso de uma paciente no terceiro mês de gravidez, que acusou pericondrite do pavilhäo auricular direito, em consequência de acupuntura realizada para controle de peso corporal. Discutem a patogenia da pericondrite, os tratamentos, clínico e cirúrgico, e a evoluçäo para deformidade cosmética severa, se as condutas terapêuticas näo forem iniciadas de imediato. Este caso sugere que a acupuntura näo se faz sem riscos, como vem sendo difundido, e mostra que podem ocorrer complicaçöes com esse tipo de tratamento

Esquistossomose mansônica: forma tumoral cerebral: relato de caso / Schistosomiasis mansoni: cerebral tumor form: case report

Relatamos um caso de esquistossomose mansônica no Sistema Nervoso Central, apresentando-se sob a forma tumoral. O paciente, de 16 anos, apresentou história de cefaléia há 2 meses, acompanhada de vômitos, tonteira e lipotímia, 15 dias antes da internaçao. O exame físico foi normal. A tomografia axial computadorizada do crânio revelou área hipodensa córtico-subcortical na regiao parietal direita, com efeito de massa sobre ventrículo lateral homolateral, hipercaptante à injeçao de contraste e de aspecto nodular. Feita ressecçao cirúrgica, o exame histopatológico evidenciou tecido encefálico com denso infiltrado crônico, granulomatose multifocal e áreas de necrose circundando ovos de Schistossoma mansoni. A biópsia retal identificou ovos viáveis de S. mansoni. Foi feito tratamento com praziquantel 60 mg/kg/dia durante 7 dias e dexametasona 12 mg/dia. Chamamos a atençao para esta forma rara de neuroesquistossomose, com manifestaçao tumoral de efeito de massa e reaçoes sorológicas negativas, inclusive no liquor. O diagnóstico somente foi estabelecido através da intervençao cirúrgica.