Negative Pressure Wound Therapy in Spinal Surgery.

Negative pressure wound therapy (NPWT) has demonstrated promise in the management of surgical site infections as well as assisting in surgical wound healing. In this manuscript, we describe the mechanisms and applications of NPWT for surgical wounds and existing evidence for NPWT in cardiac, plastic, and general surgery, followed by a discussion of the emerging evidence base for NPWT in spinal surgery. We also discuss the different applications of NPWT for open wounds and closed incisions, and the promise of newer closed-incision NPWT (ciNPWT) devices. There is nominal but promising prospective evidence on NPWT's efficacy in select at-risk populations for post-operative wound complications after spinal surgery. As there is currently a paucity of robust clinical evidence on its efficacy, rigorous randomized prospective clinical trials are needed.

Outpatient hysteroscopic removal of intrauterine devices in early pregnancy: feasibility and outcomes.

OBJECTIVE: To describe our experience with outpatient hysteroscopy for removal of intrauterine devices (IUDs) in pregnant patients, along with the pregnancy-related outcomes. DESIGN: Retrospectively and prospectively collected data between January 2015 and April 2021. SETTING: Hysteroscopic outpatient clinic (See and Treat Clinic) at a university affiliated, tertiary medical center. PATIENT(S): Forty-one patients with an inadvertent but desired pregnancy up to 12 weeks + 6 days gestational age with an IUD in situ, with documented failed attempts of IUD removal. INTERVENTION(S): After ultrasonographic confirmation of IUD location, gestational age, and viability, a small-caliber hysteroscope was introduced via a vaginoscopic approach. The uterus was distended using 0.9% normal saline until a clear view was achieved. On visualization, the IUD was grasped by its strings, tail, or lateral arm using a semirigid hysteroscopic grasper. Oral antibiotic prophylaxis was prescribed in all cases. MAIN OUTCOME MEASURE(S): The primary outcome of interest was term delivery, from 37 weeks of gestation. Secondary outcomes included patient-reported tolerability and satisfaction, and procedure-related and pregnancy related complications. RESULT(S): The procedure was completed successfully in all 41 patients. Thirty-three patients continued their pregnancies, resulting in 32 full-term singleton deliveries and 1 singleton preterm delivery at 33 + 4 weeks. Median gestational age at delivery was 39 weeks, with a median birthweight of 3,450 grams. Eight patients (19.5%) miscarried, 4 of these within a week of the procedure. CONCLUSION(S): In cases of desired pregnancy with an IUD, outpatient hysteroscopic removal of the IUD is a safe and effective management option. Broader uptake of outpatient hysteroscopy and development of hysteroscopic skills will allow more clinicians to offer patients this effective solution.

Primary intracranial marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue arising in the lateral ventricle: Case report and review of pathogenesis.

Background: Primary central nervous system lymphoma (PCNSL) is an aggressive extranodal subtype of nonHodgkin's lymphoma. Ventricle-predominant PCNSL, arising in the CNS ventricular system, is a rare entity. In over 90% of cases, PCNSL is classified as diffuse large B-cell lymphoma. Rarely, PCNSL may be classified as marginal zone B-cell lymphoma (MZBCL) of mucosa-associated lymphoid tissue (MALT). Taken together, a primary MALT-type MZBCL arising in a cerebral ventricle is an extremely rare presentation. Case Description: A 69-year-old female presented with a persistent left frontal headache for 1 year. Magnetic resonance imaging revealed an enhancing soft-tissue lesion within the left lateral ventricle, with associated periventricular edema. We performed an excisional biopsy of the tumor, which grossly had the appearance of a meningioma. Histopathology of the tumor was consistent with MZBCL of the MALT type. The patient was treated with Rituximab and Ibrutinib. Six months after surgery, she remained neurologically intact and free of disease. Conclusion: We report the case of a primary MALT-type MZBCL arising in the CNS ventricular system, with characteristics mimicking meningioma. This lymphoma involved the lateral ventricle and likely originated from the choroid plexus. Meningothelial cells and epithelial cells in the choroid plexus may acquire MALT in response to chronic inflammatory stimuli, such as infection or autoimmune disease. In rare cases, MALT lymphoma may develop as part of this pathogenesis.

Frequency of hand movements as a possible diagnostic tool for parkinsonian bradykinesia. Proposal of a simple bedside test.

BACKGROUND: Bradykinesia, dysrhythmia, and decrement in hand movements (HM) are core symptoms of Parkinson's disease (PD). The maximal rate of repetitive rhythm-preserving HM can be a diagnostic tool for PD bradykinesia. OBJECTIVES: To improve the clinical diagnosis of bradykinesia by identifying the frequencies at which rhythmic HM become irregular in PD patients compared to healthy age-matched controls. METHOD: Forty PD patients and 16 controls were asked to alternately perform left and right hand movements following the rate of a metronome with sound stimulation beginning at 85 beats per minute (BPM) and increasing in increments of 15 BPM up to 355 BPM. The rhythm of the HM for each rate was assessed visually, and the threshold frequency at which the subject could no longer rhythmically continue HM was measured by the metronome. The increasing rates of HM until reaching that threshold were compared between patients with PD and controls. RESULTS: The mean rates of a metronome in PD vs. healthy subjects were 173.3 ± 42.0 vs. 248.8 ± 48.5 BPM (p < 0.001) and 164.8 ± 34.2 vs. 241.2 ± 40.1 BPM (p < 0.001) for the dominant and non-dominant hands, respectively. The areas under the ROC curve were 0.929 [95%CI: (0.86-0.99)] for the dominant hand and 0.947 [95%CI: (0.88-1.0)] for the non-dominant hand. The BMP score cut-off value was 208 (sensitivity 72.7%, specificity 100%) for the dominant hand and 206 (sensitivity 87.5%, specificity 95%) for the non-dominant hand. CONCLUSIONS: The proposed test quantified the frequencies of rhythmic HMs in PD patients vs. controls and improved the diagnosis of bradykinesia in PD patients.

Incidence of acute ischemic cerebrovascular events in a cohort of HIV-infected patients.

The prevalence of vascular diseases in HIV (human immunodeficiency virus)-infected individuals has been comprehensively investigated. However, their incidence of ischemic cerebrovascular events has not been thoroughly examined. Our aim was to examine the rate of ischemic stroke or TIA (transient ischemic attack) in a defined HIV population and to find the risk factors that are characteristic in this population. A case-controlled retrospective cohort study of HIV patients followed up at Kaplan Medical Center between 2009 and 2017 was performed. The study included 300 patients who had been compared to a matched age and gender group. The data were collected by reviewing patients' files and imaging studies. The first goal was to compare the incidence of ischemic cerebrovascular events in both groups. Secondary endpoints were to characterize the types of cerebrovascular events and risk factors in the study group versus the general population. There were more ischemic stroke cases in the study group vs. the control group. After adjusting for vascular risk factors in a multivariate analysis, the odds ratio for a cerebrovascular accident in the HIV patient group was 2.29 (p = 0.057). Notably, in the comparative group, the vascular risk factors' rate (hyperlipidemia, IHD and smoking) was higher than in the HIV group. In this study, ischemic cerebrovascular events were more common in HIV-infected patients than in the control group, in spite of the fact that they had fewer vascular risk factors.

Unilateral mimicking bilateral BPPV- a forgotten entity? Characteristics of a large cohort of patients, comparison with posterior canal BPPV and clinical implications.

OBJECTIVE: Unilateral mimicking bilateral benign paroxysmal positional vertigo (umb-BPPV) was attributed to inappropriate head positioning during testing of the posterior canal. Despite its inclusion in the Diagnostic criteria for the classification of vestibular disorders of the Bárány Society, the clinical characteristics and treatment responsiveness of this BPPV subtype have not been intensively studied. METHODS: Records of patients with BPPV seen at a single outpatient dizziness clinic during the years 2000-2020 were reviewed. Eighty seven patients with umb-BPPV and 86 random patients with posterior canal BPPV (p-BPPV) were retrieved. Their demographics and BPPV characteristics were analyzed. RESULTS: Patients' and BPPV characteristics were similar in umb- and p-BPPV except for the prevalence of males in the umb-BPPV group. No differences were found between treatment responsiveness and recurrences in both groups. The recurrence rate of umb-BPPV was not influenced by age, gender, BPPV side, duration of symptoms or treatment responsiveness during the first attack. CONCLUSIONS: In accordance with our hypothesis about mixed canalo- and cupulolithiasis as the underlying mechanism of umb-BPPV, patients did not differ in characteristics and treatment responsiveness from p-BPPV patients. Recognition of umb-BPPV is important since inappropriate treatment can cause an unnecessary delay in therapy success.

Intravenous Lacosamide in Seizure Clusters: Dose and Efficacy.

PURPOSE: The objective of our study was to evaluate the relationship between the loading dose and efficacy of lacosamide (LCM), when used in seizure clusters (SCs). METHODS: A cohort of patients with SC treated with intravenous (IV)-LCM between September 2017 and September 2019 was retrospectively examined. Demographic data, type of seizure emergency, etiology, response rate, previous oral antiepileptic drugs used, total LCM loading dose, and side effects were reviewed. RESULTS: Thirty-nine cases of epileptic emergencies treated with IV LCM were collected. The mean age was 59.25 years (18-88 years), and the median loading dose was 136.5 mg (100-300 mg) with a response rate in the whole population of 29.2%. Nine patients received a loading dose of 200 to 300 mg, and their response rate was 89%. Common side effects (drowsiness and dizziness) were mild. No electrocardiogram changes or other cardiovascular side effects, or unexpected side effects were seen. CONCLUSIONS: In adults with SC, a loading dose of IV LCM of 200 mg or more achieved 89% response rate in this cohort. Loading doses of less than 300 mg caused mild side effects only.

Creutzfeldt-Jakob and Vascular Brain Diseases: Their Overlap and Relationships.

Only a few case reports of stroke-like onset of Creutzfeldt-Jakob disease (CJD) have previously been published. We aimed to analyze the neurological, imaging, electroencephalographic (EEG), and laboratory features of patients with this very rare phenomenon. Here, we review the clinical characteristics, onset features, and clinical course variants of stroke-like CJD in 23 such patients. The median age of the patients was 71 years (range: 56-84 years); 12 were women. In 20 patients, CJD was sporadic. Thirteen patients developed apoplexy-like onset of symptoms, whereas the others had prodromal non-specific complaints. Most often the patients manifested with pyramidal signs (n = 13), ataxia (n = 9), and aphasia (n = 8). On MRI DWI sequence, all subjects had abnormal hyperintensities in various parts of the cerebral cortex, striatum, or thalamus, while EEG detected periodic triphasic waves only in 11. CSF 14-3-3 protein and total τ-protein were abnormal in 17 of 23 cases. All patients died, median lifespan being 2 months (range: 19 days-14 months). In conclusion, a complex of clinical, radiological, and laboratory manifestations of stroke-like onset of CJD is outlined. The clinical relationships between CJD and stroke are considered, in an attempt to highlight this rare presentation of an uncommon disease.

Case report: Isolated muscle neuromyotonia, as presenting feature of Isaacs' syndrome.

An autoimmune form of Isaacs' syndrome is commonly associated with VGKC complex antibodies and characterized by continuous muscle activity of extremity muscles. Here, we describe a CASPR2 and LGI1 positive patient with neuromyotonia clinically and electrophysiologically isolated to gastrocnemius muscles only. IVIG course and plasma exchange were ineffective, but symptoms significantly improved after a course of high-dose steroids. This case demonstrates that focal hyperexcitability should raise suspicion for autoimmunity. LGI1 antibody can be positive in patients with only peripheral nerve system involvement and if one treatment fails, other should be tried.

Safety of medical second trimester abortions for women with prior cesarean sections.

PURPOSE: Medical second-trimester abortion in women with prior cesarean section (CS) is becoming an increasingly common phenomenon. However, data about the safety of the procedure are limited. This study addresses this issue. METHODS: Retrospective cohort single-center study, done in Hadassah Medical Center in Jerusalem, a tertiary-care university hospital. This study included 779 women who needed pregnancy termination between 13 and 26 gestational weeks. 128 women had at least one previous CS (study group), whereas 651 had no CS (reference group). Protocols used were: (1) misoprostol tablets, 800 mcg vaginally followed by 400 mcg orally every 3 h up to four oral doses, (2) Oxytocin drip. Nearly one-fourth of the women received mifepristone as a preliminary treatment for cervical ripening. The outcomes assessed included the following complications: retained placenta, bleeding with or without requiring blood transfusion, infection, cervical lacerations, uterine adhesions and uterine ruptures. RESULTS: Previous CS does not appear to increase the incidence of complications, excluding clinical bleeding without requiring blood transfusions (p value 0.05), which has a minimal clinical significance. Oxytocin protocol had 3.44 OR for complications, compared to misoprostol (p value 0.03, CI; 1.12- 10.52). No significant correlation was found between Misoprostol dosage and complications (Mann-Whitney U test, p value 0.057). CONCLUSION: Medical second-trimester abortions for women with prior CS should be considered a safe and effective procedure, with a low complication rate. The most serious complication is uterine rupture, which is uncommon; we recorded one case only. Misoprostol protocol should be preferred. CLINICAL TRIAL NUMBER AND DATE: IRB 0177-17-HMO, 5/2014.

Single- versus multiple-dose methotrexate in cesarean scar pregnancies management: treatment and reproductive outcomes.

PURPOSE: We aim to assess the outcome of the treatment of cesarean scar pregnancy (CSP) with single-dose methotrexate (MTX) versus multiple-dose MTX protocols. METHODS: A retrospective cohort study including two tertiary medical centers was conducted. All women diagnosed with CSPs between the years 2011 and 2019 that were initially managed with systemic MTX were included. Single-dose MTX practiced in one medical center was compared to multiple-dose MTX, practiced in the other medical center. RESULTS: The study cohort included 31 women in the single dose and 32 women in the multiple-dose MTX groups. Baseline characteristics did not differ between groups. The primary outcome occurred in 12 (38.7%) of the cases in the single-dose group and in 6 (18.8%) in the multiple-dose group (p = 0.083). The rate of conversion to surgical treatment was similar in both groups (4 vs. 5 in the single vs. multiple-dose groups, respectively, p = 0.758). There was no significant difference between the single- and the multiple-dose groups in the administration of blood products (16.1% vs. 3.1%, respectively, p = 0.104), total days of admission (18 ± 9.3 vs. 17 ± 12.8 days, respectively, p = 0.850), and readmission rate (32.3% vs. 21.9%, respectively, p = 0.353). Data regarding sequential pregnancies were available for 11 women in the single and 13 women in the multiple-dose MTX groups. There were no differences between the groups in rates of term deliveries, CSP recurrence, and abortions. CONCLUSION: Both single- and multiple-dose MTX treatment protocols offer high success rate with a relatively low complication rate in the treatment of CSP.

Pelvic inflammatory disease among users and non-users of an intrauterine device.

The correlation between pelvic inflammatory disease (PID) and a present intrauterine device (IUD) has been debated. We aimed to evaluate the differences between IUD users and non-users among women hospitalised with a diagnosis of PID. Our hypothesis was that the role of a present IUD among PID patients is minimal, if any. We performed a retrospective cohort study during 2010-2018 in a tertiary university hospital. Overall, 474 hospitalised patients were diagnosed with PID. Of these, 121 patients were IUD users. The patients without an IUD were younger and had lower gravidity and parity. Among the patients without an IUD, higher rates of prior history of PID and fever at presentation were noticed. In 23.9% (29/121) of women, the IUD was inserted less than four weeks prior to the PID diagnosis. The patients with an IUD insertion-associated PID, had lower rates of tubo-ovarian abscess (2 (6.9%) versus 24 (26.0%), OR [95% CI] 0.18 (0.04-0.84), p = .02) at presentation, as well as a shorter length of stay (LOS) (median 4 versus 5 days, p = .05). In a patient in whom the IUD was retained, hospitalisation period was shorter (median LOS 4 days versus 5 days, p = .007). PID inpatients who carry an IUD represent a specific subset of patients with a milder disease.Impact statementWhat is already known on this subject? The correlation between pelvic inflammatory disease (PID) and a present intrauterine device (IUD) is debateable.What the results of this study add? PID inpatients who carry an IUD represent a specific subset of patients with milder disease.What the implications are of these findings for clinical practice and/or further research? Our results show that in IUD users with PID, the practice of IUD removal as part of their PID treatment is of little benefit.

Secondary encephalocele in an adult leading to subdural empyema.

Brain abscesses are an uncommon but potentially fatal infection. They can spread directly from an adjacent source or hematogenously from a distant source. Encephaloceles represent a rare form of neural tube defects that can potentially be complicated by the development of meningitis or brain abscess. We report a case of a 63-year-old female who presented with bilateral lower extremity weakness and was ultimately found to have a Streptococcus pneumoniae subdural empyema and an associated frontal lobe encephalocele extending through the left frontal sinus. She was treated with surgical drainage, intravenous antimicrobials, and ultimately surgical repair of the encephalocele. This report highlights a unique presentation of brain abscess. Clinicians should be aware of this potential infectious complication of a neural tube defect.

Outcome of methotrexate treatment for ectopic pregnancies among obese women.

OBJECTIVE: Single dose administration of methotrexate (MTX) is considered the first line of treatment in selected patients with an ectopic pregnancy (EP). However, data regarding MTX efficacy among obese patients is limited. We sought to investigate the efficacy of MTX single dose regimen among obese patients MATERIAL AND METHODS: A retrospective cohort study conducted at a gynecology department in a tertiary teaching hospital, between January 2010 and December 2018, including women diagnosed with an EP and treated by a single-dose regimen of MTX. We compared success rate and gestation characteristics between obese and non-obese women. RESULTS: Overall, 195 women were treated with single-dose intramuscular MTX for EP during the study period. Of those, 31 women (15.9%) were obese (BMI ≥ 30 kg/m2) and the rest 164 (84.1%) were of normal body weight. Median MTX dosage for the obese group was 95 milligrams (IQR 91-104) vs. 83 milligrams (IQR 78-87) for the non-obese group. Treatment success rate of the overall cohort was 66.6% (130/195) and treatment success rate of single-dose MTX was comparable between the obese and non-obese groups (64.5% vs. 67.0%, p = 0.78). Obese patients were older as compared to non-obese (median age 33 vs. 29, p = 0.03). In multivariate logistic regression analysis, percentage hCG change from day 1 to day 4 was the only factor associated with treatment success (aOR 1.02; 95%CI 1.01, 1.04, p < 0.001). CONCLUSION: Single-dose MTX treatment among obese patients diagnosed with ectopic pregnancy led to similar success rates as compared to non-obese patients.

Intraoperative Ultrasound Guidance During Curettage After Second-Trimester Delivery is Associated With a Higher Rate of Complications.

OBJECTIVE: The use of intraoperative ultrasound guidance for second-trimester elective dilation and curettage reduces the incidence of uterine perforation. However, the role of intraoperative ultrasound guidance during curettage following second-trimester delivery has not been evaluated. We aim to evaluate the effect of intraoperative ultrasound guidance during curettage following second-trimester delivery. METHODS: We conducted a retrospective cohort study that included patients who had a second-trimester delivery at up to 236/7 weeks gestation and underwent uterine curettage after the fetus was delivered. RESULTS: Overall, 273 patients were included. Of them, 194 (71%) underwent curettage without intraoperative ultrasound guidance, while 79 (29%) underwent the procedure utilizing intraoperative ultrasound guidance. The overall rate of a composite adverse outcome was higher among those undergoing curettage under intraoperative ultrasound guidance compared with no ultrasound guidance (31 [39.2%] vs. 40 [20.6%]; OR 2.4; 95% CI 1.4-4.4, P = 0.002). Placental morbidity (10 [12.6%] vs. 11 [5.6%]; OR 1.9; 95% CI 1.01-5.9, P = 0.04) and infectious complications (6 [7.5%] vs. 5 [2.5%]; OR 3.1; 95% CI 1.01-10.4, P = 0.05) were more frequent among those undergoing curettage with intraoperative ultrasound guidance. In a multivariate logistic regression analysis, intraoperative ultrasound guidance was the only independent factor positively associated with the occurrence of an adverse outcome (adjusted OR 1.93; 95% CI 1.1-3.4, P = 0.02). Procedure time was longer when ultrasound guidance was used (9:52 vs. 6:58 min:s; P < 0.001). CONCLUSION: Intraoperative ultrasound guidance during curettage after second-trimester delivery is associated with a higher complication rate than no guidance.

Success rate of methotrexate treatment for recurrent vs. primary ectopic pregnancy: a case-control study.

The aim of this study was to compare the success rate of methotrexate (MTX) treatment in patients with recurrent ectopic pregnancy (REP) and primary EP (PEP). A retrospective cohort study. The study cohort comprised all patients diagnosed with an EP and treated by intention with single-dose regimen of intramuscular MTX in a tertiary medical centre during 2010-2018. Cases (REP) and controls (PEP) were compared.262 patients had PEP and 32 had a REP. Women with REP had significantly higher gravidity order and higher incidence of previous abortions (5 vs. 3, median, p < .001, 59.3% vs. 32.8%, p < .001, respectively). Women with REP had a higher proportion of a history of previous surgery in general, and specifically pelvic surgery (46.8% vs. 20.6%, p < .001, 24.4% vs. 7.2%, p < .001, respectively). Treatment success was lower in the REP group (40.6% vs. 66.4%, p = .006, Odds ratio 0.34, 95% confidence interval 0.16, 0.73). In a logistic regression analysis, the only factor found to be independently associated with treatment failure was REP (adjusted odds ratio 0.30, 95% confidence interval 0.12, 0.77, p = .01). Our study suggests that medical treatment success with a single-dose regimen of MTX is lower than expected among REP cases, suggesting that different treatment approach should be considered in this setting.Impact statementWhat is already known on this subject ? There is paucity of data regarding success rate of methotrexate treatment for a recurrent ectopic pregnancy (REP).What do the results of this study add? Medical treatment success with a single-dose regimen of MTX in patients with a REP is lower than expectedWhat are the implications of these findings for future clinical practice and/or further research? As medical treatment success with a single-dose regimen of MTX for women with a REP is lower than expected, different treatment approach should be considered. Further and prospective studies with a larger sample size are needed to confirm our findings.

Risk factors for recurrent Pelvic Inflammatory Disease.

OBJECTIVE: Pelvic inflammatory disease (PID) is a common infection which can result in severe long term morbidity, such as chronic pelvic pain and infertility. The morbidity increases in correlation to the number of PID events. Our study aim to assess the risk factors for recurrence of pelvic inflammatory disease. METHODS: A retrospective case control study was conducted using data for all women who were admitted to a tertiary medical center for a recurrent PID over a duration of 15 years. Women who had a recurrent PID were compared to women admitted for PID treatment without further recurrence. Forward stepwise multivariate logistic regression analysis was subsequently carried out. RESULTS: The study included 133 women of whom 33 had recurrent PID. Women in the recurrent PID group had a higher rate of previous pelvic surgery (12 (36 %) vs. 20 (20 %), adjusted odds ratio [OR] 2.2 (95 % confidence interval CI 1.06-5.4, p = 0.05) and more had intrauterine devices (IUD) still in place if they had been previously present (5 (71.4 %) vs. 9(25.7 %), OR 7.2, (95 % CI 1.18-43.9), p = 0.02). The majority were treated with a combination of Ampicillin and Gentamycin, fewer received Augmentin or a cephalosporin base regimen (28 (84.8 %) vs 56 (56.0 %), OR 4.4, (95 % CI 1.5-12.3, p = 0.02), (1 (3.0 %) vs 27 (27.0 %), OR 0.08, (95 % CI 0.01-0.64), (4 (12.2 %) vs 17 (17.0 %)) respectively. In addition, invasive treatment had been required in more patients who later had a recurrent PID (6 (18.1 %) vs. 4(4.0 %), OR 5.3 (95 % CI 1.1.4-20.2), p = 0.007). Antibiotic regimens and invasive treatment were independently associated with recurrent PID (OR 2.69; 95 % CI 1.13-6.41, OR 2.10; 95 % CI 1.19-3.71, respectively). CONCLUSION: Among women with PID, special awareness should be given to women with previous pelvic surgery, who required an additional interventional treatment and have an IUD inserted. Efforts should be made to achieve treatment success and optimal prevention to prevent recurrent PID.

Conservative management of Caesarean scar pregnancies with systemic multidose methotrexate: predictors of treatment failure and reproductive outcomes.

RESEARCH QUESTION: Caesarean scar pregnancy (CSP) is an increasing concern in modern obstetrics. Early diagnosis and management are of utmost importance. The optimal management approach for CSP is not well established, with various treatment modalities reported. The role of conservative management of CSP has been previously reported, with conflicting results. This study aimed to further evaluate its role and better delineate the subsequent reproductive outcomes. DESIGN: A retrospective cohort study including all patients diagnosed with a CSP and treated by intention of conservative management with systemic methotrexate (MTX). Maternal and gestation characteristics were compared between treatment success and failure groups. RESULTS: Thirty-six cases of CSP were encountered. Overall, 29/36 (80.6%) were treated by systemic injection of MTX while the other 19.4% had combined systemic and local (i.e. intra-sac) MTX treatment. Invasive intervention was needed in five (13.9%) cases (failure group). Among those successfully treated with MTX, the median time to resolution was 22 (interquartile range 13-37) days. Cases who were converted to surgical treatment had a higher number of previous Caesarean deliveries (median 4 versus 2, P = 0.002). In logistic regression modelling, the number of previous Caesarean deliveries was the only factor independently associated with conversion to surgical management (odds ratio 2.02, 95% confidence interval 1.03-3.94). The majority of future pregnancies ended at term pregnancy with only one preterm delivery due to severe intrauterine growth restriction. CONCLUSIONS: Systemic MTX therapy is a safe and effective strategy for the treatment of CSP, with favourable subsequent reproductive results and a low conversion rate to surgical management.

Risk factors for recurrent ectopic pregnancy following single-dose methotrexate treatment.

Objective: Our study aimed to investigate the predisposing factors for recurrence of an ectopic pregnancy (EP) following single-dose methotrexate (MTX) treatment for a primary EP. Methods: This was a retrospective cohort study performed in a tertiary care medical centre including all patients diagnosed with primary EP and treated with a single-dose regimen of intramuscular MTX. EPs with future recurrence were compared with first time only EPs, to identify risk factors for recurrent EP. Forward stepwise multivariate logistic regression analyses were subsequently carried out. Results: The study included 272 women. Of those, 22 (8.1%) had a recurrent EP. Women in the recurrent EP group had a higher rate of abortions (45.5% vs 32.7%; p = 0.02), previous pelvic surgery (45.5% vs 6.5%; p < 0.001) and both pelvic and uterine surgery (4.5% vs 1.6%; p < 0.001). Conception by assisted reproductive technology (ART) was more common among the non-recurrent EP group (23.0% vs 4.5%; p = 0.04). Success of single-dose MTX treatment was lower in the recurrent EP group compared with the non-recurrent EP group (36.4% vs 65.7%; p = 0.006). A history of pelvic surgery was independently associated with recurrent EP (adjusted odds ratio [OR] 17.6; 95% confidence interval [CI] 4.9, 63.2; p = 0.001). Treatment success of single-dose MTX was independently protective for recurrent EP (adjusted OR 0.25; 95% CI 0.08, 0.76; p = 0.02). Conclusions: Among women with an EP, attention should be paid to those with previous pelvic surgery. Efforts should be made to achieve medical treatment success to prevent recurrent EP.