Therapeutic options of caesarean scar pregnancy: case series and literature review.

We describe our experience with the treatment of 4 caesarean scar pregnancies and provide an overview of current literature. Four women diagnosed with a caesarean scar pregnancy in our hospital between 1996 and 2007 were treated with local or systemic methotrexate and had a steady decline of the serum beta-hCG level. The uterus was preserved in all women and 3 of them had an uneventful subsequent pregnancy and delivery. We suggest that transcervical needle aspiration of amniotic fluid followed by intra-amniotic injection of methotrexate should be the treatment of choice, followed by surgical treatment only if methotrexate fails.

Perinatal dioxin exposure, cytochrome P-450 activity, liver functions and thyroid hormones at follow-up after 7-12 years.

OBJECTIVES: Prenatal and lactational exposure to Dutch "background" dioxin levels may cause health effects spanning many years. In addition, perinatal studies have shown a relationship between dioxin exposure and thyroid disturbance. To assess the later health effects of prenatal and lactational dioxin exposure on liver function we measured plasma ALAT and ASAT levels amongst our longitudinal cohort, as was done perinatally and at 2(1/2) years. The children underwent a caffeine loading test to determine CYP1A2 activity. To assess the later effects on thyroid function we measured plasma TSH and FT4. STUDY DESIGN: A longitudinal cohort of 37 healthy children (age 7-12, mean 8.2 years), with documented prenatal and lactational dioxin exposure, ingested 3mg caffeine/kg BW 6h prior to blood withdrawal. Paraxanthine/caffeine molar ratio, ALAT, ASAT, TSH and FT4 were determined in venous blood. RESULTS: Linear regression of ASAT and ALAT revealed no relation with prenatal and lactational dioxin exposure. No correlation was found between the paraxanthine/caffeine molar ratio and prenatal and lactational dioxin exposure. Linear regression of TSH and FT4 revealed no relation with prenatal and lactational dioxin exposure. CONCLUSION: This follow-up has shown a normalisation of previously abnormal ALAT and ASAT levels, indicating a transient effect. CYP1A2 activity, measured by means of a caffeine-loading test, revealed no correlation with the prenatal and lactational exposures. A normalisation of previously abnormal thyroid hormone homeostasis was seen, also possibly indicating a transient effect. This study provides new data on long-term follow-up after perinatal dioxin exposure to background levels of dioxins.

Persistent hematologic and immunologic disturbances in 8-year-old Dutch children associated with perinatal dioxin exposure.

Perinatal exposure to Dutch "background" dioxin levels in 1990 was high, but comparable with that of other industrialized Western European countries. Exposure during the sensitive perinatal period may cause permanent disturbances. Therefore, we assessed the health status and various hematologic and immunologic parameters among our longitudinal cohort. A medical history was taken and venipuncture performed in a longitudinal cohort of 27 healthy 8-year-old children who had documented perinatal dioxin exposure. Linear regression revealed a decrease in allergy in relation to prenatal (p = 0.02) and postnatal (p = 0.03) dioxin exposure. Increases in CD4+ T-helper cells (p = 0.006) and in CD45RA+ cells (p = 0.02) were seen in relation to postnatal exposure. A persistently decreased platelet count (p = 0.04) and increased thrombopoietin concentration (p = 0.03) were seen in relation to postnatal exposure. This follow-up has shown a decrease in allergy, persistently decreased thrombocytes, increased thrombopoietin, and increased CD4+ T-helper and increased CD45RA+ cell counts. This study provides indications of effects at the stem cell level of perinatal dioxin exposure, persisting until minimally 8 years after birth.

Electronic patient records: domain message information model perinatology.

PURPOSE: The Netherlands is developing a set of national domain information models to support electronic information exchange and electronic patient records (EPR). These domain information models aim to support the development, adoption, implementation and maintenance of the EPR in Dutch healthcare practice. This article describes the modelling for a pilot for mother- and childcare (perinatology). METHODOLOGY: Cases' from perinatology are modelled using the Health Level 7 version 3 Reference Information Model (HL7 RIM) as the methodology and tools. RESULTS: Results include descriptions of care processes, communication and information that are broken down into interaction tables and tables with information. Next several domain information models for perinatology are drawn up. These models allow healthcare professionals to recognise their communication, content and work. Currently, the models facilitate discussion and critique by clinician and informaticians. CONCLUSION: The perinatology domain information models facilitate in building implementations because they contain sufficient details for EPR developers and for developers of messages for information exchange. The first results of the project are useful, despite the fact that HL7 RIM modelling methodology is still not finalized. The approach bridges professional content, technical implementation of messages, and future EPR development.

Use of a web portal for support and research after a disaster: opportunities and lessons learned.

BACKGROUND: In this report we describe the development and use of a web portal in the aftermath of the 2004 tsunami. This large scale disaster confronted many displaced people with death, despair and need for information and support. Awareness and insight in the emotional impact of disasters can provide opportunities for surveillance and early treatment. Moreover, online support systems can contribute to community building, empowerment of victims and resilience. OBJECTIVE: We evaluate the development and use of a multilingual web portal that combined a platform for information, emotional support, self assessment and referral with research opportunities. The rapid development, use, advantages, difficulties and learning points are discussed. METHODS: A multidisciplinary working group from the University Medical Centre Utrecht, the Major Incident Hospital and the Central Military Hospital developed a web portal for tsunami victims. The webportal combined: (1) a forum aimed at community building, (2) self assessment tools that in the same time function as a reseach survey, (3) e-consultation, and (4) an information portal. RESULTS: Within 3 weeks after the tsunami, the working group launched an open, online service (www.TISEI.org. Tsunami Intrenational Survey on Emotional Impact) to foster community) support in the aftermath of the disaster. It combined four functionalities that were earlier previously only used separately. The portal had over 36.800 unique visitors in the first two years. At least 31% (144/464) percent of the Dutch surviving victims could be reached for a survey through the site. The TISEI-environment was available in 15 languages and visitors came from all over the world. Ninety-five percent of all visitors came from Europe or the United States. Subsequent to immediate disaster support, the web portal also served as a memorial archive for anniversary meetings and follow-up incentives. Difficulties we experienced were lack of funding, time pressure, victim-anonymisation, international collaboration and long term maintenance. CONCLUSIONS: A multilingual website with combined modalities for emotional care and research after a natural disaster proved feasible. Web based services like www.TISEI.org in the aftermath of mass disasters can help community building and deliver low level, patient centred and easily accessible information and care. A multilingual website with combined modalities for emotional care and research after a natural disaster proved feasible. Growing Internet penetration world wide and especially the rapid expansion and influence of online communities enables delivery of care and perform research with the internetInternet as a platform. The unpredictable nature of disaster does put time pressure on the development of online solutions and influenced the yield of our site. This highlights the necessity of developing methods and (inter) national collaborations in advance, secure funding, and learn from earlier initiatives.

Endometrial aspiration before or after saline infusion sonography and the effect on specimen quality: a randomized study.

STUDY OBJECTIVE: Saline infusion sonography (SIS) and endometrial aspiration can both be performed with the same catheter in 1 session. The objective of this study was to evaluate the effect of the order of investigations (aspiration-SIS vs SIS-aspiration) on the quality of the endometrial sample. DESIGN: Single-blind randomized controlled trial (Canadian Task Force classification I). SETTING: Academic teaching hospital. PATIENTS: A total of 113 women with abnormal uterine bleeding who visited the outpatient clinic were included in the study. INTERVENTIONS: The included women were randomly allocated either to SIS and subsequent endometrial aspiration, or to the reverse order. Both examinations were performed in 1 session with the same catheter. All aspiration specimens were sent to the same pathologist, who evaluated the quality of the samples. MEASUREMENTS AND MAIN RESULTS: The quality of the endometrial aspiration specimen was significantly better in the group of women who had aspiration before SIS, compared with women who were allocated to the reverse order (p=.04). Blood and mucus staining and the presence of endometrial epithelium had a significant influence on the sample quality. The difference between both groups was most pronounced in premenopausal women (p=.005). CONCLUSION: This study shows that the proportion of adequate specimens is higher when endometrial aspiration is done first with subsequent SIS. Aspiration should be performed before SIS to decrease the chance of obtaining an insufficient endometrial aspiration specimen.