Couvade syndrome: more than a toothache.

BACKGROUND: Couvade Syndrome is best characterized as a somatic symptom disorder where the partner experiences somatic symptoms during their partner's pregnancy most often during the first and third trimesters. Several psychoanalytical theories have been proposed for this disorder. There are well studied mood changes that correspond to hormonal shifts that occur in response to anticipated parenthood which serve as a physiologic mechanism for this pathology. CASE: The following is a case of Couvade syndrome in the setting of a high risk pregnancy complicated by pre-eclampsia with severe features necessitating a preterm delivery. CONCLUSION: Expectant fathers should be screened for symptoms of Couvade Syndrome throughout the pregnancy in order to better support the familial unit.

Psychotic pregnancy denial: a review of the literature and its clinical considerations.

BACKGROUND: Pregnancy denial can be broken into two major types, non-psychotic and psychotic deniers, and further classified into pervasive, affective and persistent sub-types. It can lead to increased morbidity and mortality of the mother and neonate. Psychotic pregnancy denial is rare and the medical literature existing on the subject is limited to a small number of case reports and case series. No formal recommendation exists on the clinical management of psychotic pregnancy denial in the antenatal or postpartum period. The authors provide a comprehensive review of the literature regarding psychotic pregnancy denial, present an example of an unpublished case and provide suggestions for clinical management. CASE: A 33-year-old primigravida at 37 6/7 weeks gestation presented with new-onset psychotic pregnancy denial with no prior history of psychosis. She had a negative medical work-up for organic causes of psychosis. Using a multidisciplinary approach, the decision was made to deliver the fetus at 38 1/7 weeks via cesarean section due to concerns for patient and fetal safety. Following delivery, she was admitted to an inpatient psychiatric facility and underwent 16 bilateral electroconvulsive therapy (ECT) treatments to which she showed complete response. CONCLUSION: Psychotic pregnancy denial is rare and potentially dangerous. Delivery prior to 39 weeks gestation is reasonable for worsening psychiatric disease but careful consideration of the risk-benefit analysis and ethical framework must be deliberated.Teaching points: In cases of worsening psychiatric disease in pregnancy, a multidisciplinary approach is necessary for comprehensive care. Psychotic denial of pregnancy leads to increased maternal and neonatal morbidity and mortality. Delivery prior to 39 weeks gestational age is reasonable to expedite psychiatric treatment.PrecisUsing a multidisciplinary approach, the decision to deliver before 39 weeks gestation is reasonable for worsening psychiatric disease.

Surgical simulation supplements reproductive endocrinology and infertility fellowship training.

OBJECTIVE: To assess if a surgical boot camp improves laparoscopic skill among reproduction endocrinology and infertility (REI) fellows and increases fellow desire to incorporate surgical skills into practice and to examine whether fellowship in vitro fertilization (IVF) volume correlates with surgical efficiency. DESIGN: Prospective evaluation. SETTING: Simulation Center. PATIENTS: Forty REI fellows. INTERVENTIONS: Fellows were timed before and after training in laparoscopic suturing and knot tying and while using virtual simulators. Fellows were surveyed before boot camp on prior experience with IVF and reproductive surgery, and immediately and 1 month after boot camp on their desire to incorporate surgical skills into practice. MAIN OUTCOME MEASURES: Efficiency of laparoscopic suturing and knot tying before and after boot camp; likelihood and persistence of incorporating surgical skills into practice immediately and 1 month after boot camp; and correlation between fellowship IVF volume and fellow surgical efficiency. RESULTS: Fellows experienced significant improvement in laparoscopic suturing (44 sec), intracorporeal knot tying (82 sec), and extracorporeal knot tying (71 sec). Fellows reported being more likely to incorporate operative hysteroscopy (89%), operative laparoscopy (87%), and laparoscopic suturing (84%) into practice immediately following boot camp with no difference 1 month later. Fifty-four percent of fellows reported being more likely to perform robotic surgery after the boot camp, increasing to 70% 1 month later. There were weak correlations between IVF case volume and efficiency in laparoscopic suturing or hysteroscopic polypectomy (Spearman correlation coefficients, -0.14 and -0.03). CONCLUSIONS: An intensive surgical boot camp enhances surgical skill among REI fellows.

Hysteroscopic Myomectomy of a Large Submucosal Leiomyoma with Novel Use of Fluid Warming.

Uterine myoma size is often considered a limiting factor when choosing the surgical approach to myomectomy. In this case, a 35-year-old woman presented with heavy menstrual bleeding and desire for fertility. Ultrasound performed 3 months earlier could not assess the endometrium and suggested leiomyoma. Magnetic resonance imaging of the pelvis identified a fundal submucosal myoma measuring 6.8 × 7.1 × 3.5cm. A planned staged hysteroscopic resection of the large submucosal myoma with intramural component was achieved. Unassisted conception occurred 2 months later. She delivered by cesarean section at term without complications. This case demonstrates that hysteroscopic mechanical tissue removal device combined with ultrasound guidance and a fluid warming system can complete myomectomy for very large uterine myomas without the need for laparoscopy or laparotomy.

Myeloid-derived suppressor cells regulate growth of multiple myeloma by inhibiting T cells in bone marrow.

Myeloid-derived suppressor cells (MDSC) are one of the major factors limiting the immune response in cancer. However, their role in bone marrow (BM), the site of primary localization of multiple myeloma (MM), is poorly understood. In this study, we found a significant accumulation of CD11b(+)CD14(-)CD33(+) immunosuppressive MDSC in BM of patients with newly diagnosed MM. To assess the possible role of MDSC in MM, we used immunocompetent mouse models. Immunosuppressive MDSC accumulated in BM of mice as early as 1 wk after tumor inoculation. S100A9 knockout (KO) mice, which are deficient in their ability to accumulate MDSC in tumor-bearing hosts, demonstrated reduced MDSC accumulation in BM after injection of MM cells compared with wild-type mice. Growth of the immunogenic MM cells was significantly reduced in S100A9KO mice. This effect was associated with the accumulation of Ag-specific CD8(+) T cells in BM and spleens of S100A9KO mice, but not wild-type mice, and was abrogated by the administration of anti-CD8 Ab or adoptive transfer of MDSC. Thus, the accumulation of MDSC at early stages of MM plays a critical role in MM progression and suggests that MDSC can be considered a possible therapeutic target in this disease.