Contrast enhanced computed tomography assessment of superficial inguinal lymph node metastasis in canine mammary gland tumors.

Mammary gland neoplasms are predominant in dogs. However, sentinel lymph node (SLN) status assessment criteria have not been established for these cases. In this retrospective, secondary analysis, diagnostic case control study, CT images of 65 superficial inguinal SLNs were obtained before and 1, 3, 5, and 10 min after intravenous administration of contrast agent (iopamidol 370 mgI/mL). The presence and degree of postcontrast enhancement were assessed, by means of the median absolute density value and the maximum absolute density value at any time point in the center and in the periphery of each SLN measured in Hounsfield units (HU), before and after contrast agent administration. These values were compared with histopathological findings postsurgical excision. Receiver operating characteristic analysis was conducted. The absolute density values ranged widely at each time point and within each group of nodes (negative, positive, control group). At all time points, the median density value in the center and in the periphery was significantly higher in metastatic than in non-metastatic SLNs (P ≤ .014). Among the parameters tested, the median absolute density value measured in the periphery of the SLN 3 min after injection showed the highest sensitivity, specificity, and accuracy (AUC) (87.5%, 82.1%, and 92.1% respectively), with a cutoff value of 50.9 HU. The maximum absolute density value at any time point in the center and periphery of the SLNs was also significantly higher in metastatic SLNs compared to non-metastatic (P ≤ .001). With a cutoff value of 59.5 HU, the maximum absolute density value in the periphery of the SLN displayed high sensitivity and specificity (87.5% and 89.3%, respectively). The results of this study support the hypothesis that contrast enhanced CT imaging may aid in the assessment of SLN metastasis in dogs with mammary gland neoplasms.

Three-dimensional ultrasound in the diagnosis and the classification of congenital uterine anomalies using the ESHRE/ESGE classification: a diagnostic accuracy study.

STUDY OBJECTIVE: To estimate the diagnostic accuracy of three-dimensional ultrasonography (3D US) compared to hysteroscopy/laparoscopy, in the investigation of uterine congenital anomalies using the ESHRE/ESGE classification of female genital tract congenital anomalies. DESIGN: Prospective blind, comparative, cohort study. SETTING: University Tertiary Hospital and affiliated private Hospital. PATIENTS AND METHODS: Sixty-two women consecutively referred with a suspected diagnosis of uterine congenital anomalies. The ESHRE/ESGE classification of congenital anomalies of the female genital tract was used for the description of abnormal findings. INTERVENTIONS: All patients underwent (1) 3D US and (2) hysteroscopy with laparoscopy to establish the final diagnosis. RESULTS: Concordance between 3D US and hysteroscopy with laparoscopy about the type and the classification of uterine anomaly was verified in 61 cases, including all those with septate uterus, dysmorphic uterus, bicorporeal, hemi-uterus or unicorporeal, and aplastic uterus and one out of two with normal uterus. For the diagnosis of septate uteri, which was the most common anomaly, the sensitivity of 3D US was 100%, the specificity was 92.3%, the PPV was 98% and the NPV was 100%, with kappa index 0.950. For bicorporeal, dysmorphic uterus, hemi-uteri or unicorporeal and aplastic uterus the sensitivity, specificity, PPV and NPV were all 100% with K = 1.00. Overall, 3D US showed perfect diagnostic accuracy (Kappa index = 0.945) in the detection of congenital uterine anomalies. CONCLUSION: 3D US appears to be a very accurate method for the diagnosis of congenital uterine anomalies.

Spontaneous triggering of ovulation versus HCG administration in patients undergoing IUI: a prospective randomized study.

The objective of this prospective randomized study was to assess whether spontaneous triggering of ovulation by detecting LH rise with serial serum testing, results in higher pregnancy rates as compared with administration of human chorionic gonadotrophin (HCG) in patients undergoing intrauterine insemination (IUI) in natural cycles. The trial was registered in clinicaltrials.gov as NCT01414673. Three hundred patients treated by IUI in natural cycles at the Centre of Reproductive Medicine of the Dutch-Speaking Brussels Free University were randomized to either spontaneous triggering of ovulation (spontaneous LH group) (n=150) or administration of HCG (n=150). Donor spermatozoa was used in 197/300 patients (65.67%). The duration of the follicular phase was significantly higher in the spontaneous LH group as compared with the HCG group (P=0.004). However, the ongoing pregnancy rate was significantly higher in the spontaneous LH group as compared with the HCG group (34/150 versus 16/150, P=0.008; difference 12.0%, 95% CI - 3.6 to 20.4). The use of LH for timing ovulation in natural cycles might be the best way to maximize the probability of pregnancy for patients undergoing IUI. It remains unclear whether the probability of pregnancy is associated with the mode of ovulation triggering in intrauterine insemination (IUI) natural cycles. The aim of this study was to assess prospectively whether spontaneous triggering of ovulation by detecting LH rise results in higher pregnancy rates as compared to administration of human chorionic gonadotrophin (HCG) in patients undergoing IUI. Based on our results, spontaneous triggering of ovulation is associated with significantly higher ongoing pregnancy rates compared with administration of HCG in patients undergoing IUI. Therefore, the use of LH for timing ovulation in natural cycles might be the best way to maximize the probability of pregnancy for patients undergoing IUI.

Humanin and diabetes mellitus: A review of in vitro and in vivo studies.

Humanin (HN) is a 24-amino acid mitochondrial-derived polypeptide with cyto-protective and anti-apoptotic effects that regulates the mitochondrial functions under stress conditions. Accumulating evidence suggests the role of HN against age-related diseases, such as Alzheimer's disease. The decline in insulin action is a metabolic feature of aging and thus, type 2 diabetes mellitus is considered an age-related disease, as well. It has been suggested that HN increases insulin sensitivity, improves the survival of pancreatic beta cells, and delays the onset of diabetes, actions that could be deployed in the treatment of diabetes. The aim of this review is to present the in vitro and in vivo studies that examined the role of HN in insulin resistance and diabetes and to discuss its newly emerging role as a therapeutic option against those conditions.

Bilothorax Associated with Bile Peritonitis in a Dog with No Diaphragmatic Disruption: A Case Report.

A 4-year-old intact male mixed-breed dog was presented with vomiting and severe depression of 6-day duration after being struck by a car 2 weeks before presentation. Clinical examination revealed hypothermia, respiratory difficulty, jaundice, and a bicavitary (pleural and peritoneal) effusion. Hematological and biochemical abnormalities included neutrophilic leukocytosis, increased total bilirubin concentration, and increased serum lipase activity. Biochemical and cytological evaluation of both abdominal and thoracic fluids were suggestive of bilious effusions. During celiotomy, a rupture of the cystic duct was observed, which necessitated cholecystectomy. A diaphragmatic rupture was not found. A thoracostomy tube was inserted in the right pleural space, and continuous suction was maintained for 48 hours. The dog was discharged 20 days after surgery and no abnormalities were detected on either blood tests or ultrasonographic examinations of the thorax and abdomen on follow-up examination 7 months after surgery. The presence of a bilothorax should be considered in animals with bile peritonitis, grossly intact diaphragm and pleural effusion. The exact mechanisms of the development of bilothorax are unclear, but the transport of bile through microscopic congenital or acquired weaknesses or defects of the diaphragm, via abdominal lymphatics penetrating the diaphragm and draining into the thoracic lymphatics represent the most probable route.

Comparison of diagnostic accuracy of transvaginal ultrasound with laparoscopy in the management of patients with adnexal masses.

PURPOSE: The aims of this study was (a) to compare the diagnostic accuracy of ultrasound examination with laparoscopic findings and both with the gold standard (histology) in the management of benign ovarian lesions, and (b) to assess the feasibility of laparoscopy in their diagnosis and management. METHODS: Prospective, comparative study (Canadian Task Force Classification II-2). A total of 117 women 15-59 years old were examined at outpatient department and had transvaginal ultrasound assessment. Ninety-eight women (three postmenopausal) with 105 cystic ovarian lesions met inclusion criteria and underwent operative laparoscopy. Histology was performed in all cases. RESULTS: Although laparoscopy showed an overall higher performance compared to transvaginal ultrasound, statistically significant difference was found only in the detection of endometriomas compared to ultrasound (P = 0.004 for sensitivity and P = 0.046 for specificity). CONCLUSION: Laparoscopy exhibits higher diagnostic accuracy, especially in endometriomas, compared to transvaginal scan. Laparoscopic diagnosis appears to be safe and accurate. Conservative laparoscopic management of benign adnexal masses is safe and with low morbidity.

Levonorgestrel-releasing intrauterine system vs. endometrial thermal ablation for menorrhagia.

OBJECTIVE: To evaluate the efficacy of a Levonorgestrel-releasing Intrauterine System (LNG-IUS) in controlling menorrhagia in comparison with endometrial thermal rollerball ablation. DESIGN: Seventy-nine consecutive patients with menorrhagia underwent either LNG-IUS insertion (n=42) or hysteroscopical endometrial thermal rollerball ablation (n=37) in a prospective, observational, comparative study. Women reported duration of uterine bleeding in days prior to, and six and 12 months after each intervention. Prior to each intervention, endometrial, cervical or other pathological conditions of the genital tract were excluded. GnRH analogues for endometrial suppression were given for ten weeks before endometrial ablation but not prior to LNG-IUS insertion. RESULTS: There were no differences in duration of uterine bleeding before each intervention in the two groups. The duration of uterine bleeding was lower in the LNG-IUS group as compared with endometrial ablation at six (p<0.001) and 12 months (p<0.001) after each intervention. Furthermore, the effect on reduction of bleeding was stronger in the LNG-IUS group as compared with the endometrial ablation group at six (p<0.001) and 12 months (p<0.001). CONCLUSIONS: The LNG-IUS was more efficacious than endometrial thermal ablation in reducing duration of uterine bleeding at six and 12 months post-intervention.

Surgical management of congenital uterine anomalies (including indications and surgical techniques).

The prevalence of congenital uterine anomalies (CUA) is reported to be 4.3-6.7% in the general population, 3.4%-8% in the infertile population, and 12.6-18.2% of those with recurrent miscarriages. They are the result of abnormal formation, differentiation, and fusion of the Müllerian or paramesonephric ducts during fetal life. To date, various classification systems have been proposed for the categorization of CUA, but the recently introduced ESHRE/ESGE classification seems to be a new, clear, and systematic categorization, which could be the basis for clinicians to rely on when they refer to CUA and their clinical impact either generally or concerning pregnancy outcomes. CUA are apparently related to an impaired reproductive outcome, while their exact clinical impact as well as the effectiveness of their treatment remain considered controversial. Surgery is indicated in women presenting with symptoms related to specific uterine anomalies, especially in those with fertility problems. In this review, indications, surgical techniques for the repair of CUA according to their classification, and fertility and pregnancy outcomes before and after surgery will be thoroughly reviewed.

Myomas and Adenomyosis: Impact on Reproductive Outcome.

Among uterine structural abnormalities, myomas and adenomyosis represent two distinct, though frequently coexistent entities, with a remarkable prevalence in women of reproductive age. Various mechanisms have been proposed to explain the impact of each of them on reproductive outcome. In respect to myomas, current evidence implies that submucosal ones have an adverse effect on conception and early pregnancy. A similar effect yet is not quite clear and has been suggested for intramural myomas. Still, it seems reasonable that intramural myomas greater than 4 cm in diameter may negatively impair reproductive outcome. On the contrary, subserosal myomas do not seem to have a significant impact, if any, on reproduction. The presence of submucosal and/or large intramural myomas has also been linked to adverse pregnancy outcomes. In particular increased risk for miscarriage, fetal malpresentation, placenta previa, preterm birth, placenta abruption, postpartum hemorrhage, and cesarean section has been reported. With regard to adenomyosis, besides the tentative coexistence of adenomyosis and infertility, to date a causal relationship among these conditions has not been fully confirmed. Preterm birth and preterm premature rupture of membranes, uterine rupture, postpartum hemorrhage due to uterine atony, and ectopic pregnancy have all been reported in association with adenomyosis. Further research on the impact of adenomyosis on reproductive outcome is welcome.

Management of atypical polypoid adenomyomas. A case series.

OBJECTIVE: Atypical polypoid adenomyomas (APAs) are endometrial, non-malignant, focal, and non-invasive lesions that are intriguing for their histological resemblence to invasive endometrioid adenocarcinoma or malignant mixed Müllerian tumor. The aim of this study was to present our clinical experience, regarding the reproductive outcome, the recurrence rate, and the association with hyperplasia and cancer, in a small series of patients with APA. STUDY DESIGN: Retrospective case series of patients treated for APA in a single private hospital setting from 1998 to 2016. All patients underwent diagnostic hysteroscopy and hysteroscopic removal of the lesion. Follow-up was performed annually with endovaginal ultrasonography and hysteroscopy when necessary. RESULTS: Nine patients (mean age: 37.9 years-old ±8.3years) were treated because of menorrhagia, infertility, and incidental asymptomatic endometrial lesions with operative hysteroscopy. Mean follow-up was 10.0 years (±5.8years). Three patients intended for pregnancy and 2 of them had achieved a full term delivery. There were 2 recurrences (22.2%), two cases of atypical endometrial hyperplasia (22.2%), and 2 patients with endometrioid adenocarcinoma (22.2%), all within the first 5 years. CONCLUSIONS: It appears that APAs exhibit a significant recurrence rate and they may be related both to atypical endometrial hyperplasia and endometrial adenocarcinoma; therefore, clinicians should be aware of these lesions in order to individualize treatment according to the patent's age and fertility history.

Laparoscopic management of hydrosalpinx.

Hydrosalpinx is a common cause of female infertility. Lower implantation and pregnancy rates have been reported in women with hydrosalpinges. How hydrosalpinx exerts its negative effect on the implantation process is not clearly understood. Mechanical factors, toxicity of the hydrosalpingeal fluid, and receptivity dysfunction may explain the impaired IVF outcome in the presence of hydrosalpinx. Laparoscopic surgery has a place in the diagnosis and management of hydrosalpinx. Analysis of the results of laparoscopic management of hydrosalpinx underscores the positive role of laparoscopy in fertility outcomes in women with this pathological tubal disease. Laparoscopic salpingectomy should be offered in those women who have bilateral disease or in cases where hydrosalpinges are large enough to be visible on ultrasound. Further randomized trials are required to assess other surgical treatment options for hydrosalpinx, such as laparoscopic salpingostomy, laparoscopic or hysteroscopic tubal occlusion, and drainage of hydrosalpinx before or during oocyte retrieval.

Second trimester amniotic fluid glucose, uric acid, phosphate, potassium, and sodium concentrations in relation to maternal pre-pregnancy BMI and birth weight centiles.

OBJECTIVE: To study the evolution profile of amniotic fluid (AF) glucose, uric acid, phosphate, potassium, and sodium, in the second trimester of pregnancy, and explore the possible relations between the concentration of these components and maternal, as well as neonatal characteristics. METHODS: AF of 52 pregnant women was analyzed using an automatic multichannel analyzer. Maternal age, pre-pregnancy Body Mass Index (BMI), inter-pregnancy intervals, and smoking status were derived from questionnaires. Information on pregnancy and delivery was collected from medical records. RESULTS: Uric acid increased (r = 0.423, p < 0.01), while phosphate and glucose concentrations decreased during the period of 16-26th week of pregnancy (r = -0.590, p < 0.001 and r = -0.314, p < 0.05, respectively). Maternal pre-pregnancy BMI was significantly correlated with AF uric acid concentration (r = 0.460, p < 0.01) and marginally with AF glucose (r = 0.274, p = 0.052) and sodium (r = 0.254, p = 0.070) levels. Multiple linear regression indicated that mid-trimester AF uric acid and phosphate levels were significantly related to birth weight centiles (R(2)( )= 0.345, p < 0.05). CONCLUSIONS: Our results suggest that: (a) AF phosphate levels reflect gestational age to a satisfactory extent, (b) maternal pre-pregnancy BMI is significantly correlated with AF uric acid concentration, and (c) in appropriate for gestational age infants, AF phosphate and uric acid levels may serve as potential biomarkers of birth weight centiles. Further studies on AF composition may help to unravel the biochemical pathways underlying fetal development and could offer insight on the potential impact of maternal nutritional management on fetal growth regulation.

Laparoscopy and oncology: where do we stand today?

The clinical application of laparoscopic surgery has grown rapidly over the last few years. Since the first documentations of laparoscopic lymphadenectomy, many reports highlight the use of modern laparoscopy in the field of gynecologic oncology. Laparoscopic treatment of early-stage cervical and endometrial cancer, and laparoscopic evaluation and staging of cervical, ovarian, and endometrial carcinomas, are feasible procedures. The place of minimal-access surgery in the arsenal of gynecologic oncological surgery has been established, especially after the recent developments and practical application of video laparoscopy, novel instrumentation, and advanced surgical techniques. Although operative laparoscopy in gynecologic oncology is still in its infancy the potentiality of the procedure is underscored. Many patients may benefit from the treatment or staging of gynecologic malignancies with laparoscopic means. Literature reports highlight that laparoscopy may be an effective procedure with lower morbidity and complication rates than traditional abdominal surgery. The short hospital stay and recovery time have a positive impact in a cancer patient's quality of life, as they return to normal activities rapidly. Many risks, though, may arise from the application of minimal-access surgery in cancer patients, and many questions regarding safety and efficacy need answers, based on prospective clinical trials. We must emphasize that such studies with large patient numbers and long-term follow-up are lacking. Until results from these trials are available, laparoscopic oncologic procedures should be performed only in an investigational setting by expert teams.

Cyclosporine in the management of impetigo herpetiformis: a case report and review of the literature.

A 27-year-old female, gravida 1, para 0, in week 22 of pregnancy, presented with an eruption consisting of annular erythematosquamous plaques with an active polycyclic elevated border comprised of superficial micropustules. Clinical and histological features were typical of impetigo herpetiformis (IH). Systemic steroids resulted in an unstable condition, with no resolution of lesions. Resistance to the above therapeutic scheme served as a stimulus to discuss the use of cyclosporine as a therapeutic option in this condition. Reviewing the limited literature, cyclosporine seems to serve not as a monotherapy in the management of IH but as an additional medication, in order to achieve a stable course of the disease and avoid high doses of systemic steroids.

Neurodevelopmental fetal assessment using KANET scoring system in low and high risk pregnancies.

OBJECTIVE: To assess and compare fetal behavior and neurodevelopment (KANET) between low and high risk pregnancies. METHODS: Prospective, comparative, cohort study. One hundred and fifty-two consecutive pregnant women presenting for routine 2nd trimester and 3rd trimester scan had four dimensional ultrasound examinations (4D US) in order to assess fetal behavior and neurodevelopment. This was achieved by the study of: (1) isolated head movements, (2) isolated hand movements, (3) isolated leg movements, (4) cranial sutures, (5) hand to face/head movements, (6) finger movements, (7) yawning - mouthing, (8) facial expressions, (9) isolated eye blinking, (10) "Gestalt" perception. According to the maternal background risk, the population of the study was classified in low risk pregnancies (n = 78) and high risk pregnancies (n = 74) with IUGR fetuses (n = 12), diabetes mellitus (n = 24), and pre-eclampsia (n = 38). RESULTS: The neurodevelopmental score was statistically significant higher in the low risk group compared to the high risk group (p < 0.0004). The diabetes subgroup score was statistically significantly higher compared to the IUGR and the pre-eclampsia subgroup (p = 0.0001). CONCLUSIONS: The neurodevelopment fetal assessment by 4D ultrasound appears to be a feasible technique in the evaluation of high risk pregnancies. Further studies where any association between KANET score and neurological outcome of the childhood are warranted.

Correlation of 2nd trimester amniotic fluid amino acid profile with gestational age and estimated fetal weight.

OBJECTIVES: Our aim was to identify and quantitate free amino acids in human amniotic fluid (AF) specimens collected during 2nd trimester amniocentesis and determine the correlation between amino acid concentrations, gestational age, and estimated fetal weight. METHODS: Seventy-eight AF samples were retrieved between 18 and 22 weeks of gestation. Fetal weight estimation was based on fetal biometric measurements. RESULTS: Twenty-one amino acids were quantified. The concentration of glutamine exhibited the greatest correlation with gestational age (r = 0.477, p < 0.01). Additionally, significant negative correlations were recorded between gestational age and levels of alanine, proline, lysine, valine, taurine, leucine, glutamic acid, tyrosine, phenylalanine, isoleucine, ornithine, methionine, and tryptophane (p < 0.05). After adjusting for maternal age, fetal gender, intervals between consecutive pregnancies, pre-pregnancy body mass index, and smoking during pregnancy the strength of the correlation for proline and lysine decreased. A stepwise multiple linear regression model including gestational age as a first level predictor of fetal weight indicated that lysine and cysteine concentrations were additional predictors. CONCLUSIONS: Our results suggest that AF amino acids are crucial for fetal growth. Our purpose was not to establish an immediate diagnostic application. However, further exploration is likely to be fruitful, especially in high-risk pregnancies.

Laparoscopic management of mesenteric cyst: a case report.

Mesenteric cysts are rare intra-abdominal lesions with variable clinical symptoms and signs that make pre-operative diagnosis difficult. Optimal treatment is surgical excision of the cyst with laparotomy or laparoscopy. We present a case of mesenteric cyst that was misdiagnosed as para-ovarian cyst and managed laparoscopically by gynaecologists.

Placenta abruption in a woman with Wilson's disease: a case report.

Wilson's disease is a rare genetic disorder of copper metabolism that causes primary hepatic cirrhosis, secondary menstrual abnormalities and infertility. Following the appropriate therapy patients are asymptomatic and pregnancy may be achieved. We present a case of placental abruption in a pregnant woman with Wilson's disease and we review the management dilemmas and treatment options of pregnant women with Wilson's disease.

Laparoscopic management of unicornuate uterus with non-communicating rudimentary horn (three cases).

This article describes the laparoscopic management of unicornuate uterus with a non-communicating rudimentary horn in three women who presented with lower abdominal pain and dysmenorrhoea. The patients were managed with laparoscopic removal of the rudimentary horn along with the ipsilateral salpinx. No complications were noted intraoperatively and the patients remain asymptomatic.