Management of adnexal masses' torsion during pregnancy.

With the increased use and quality of ultrasound in pregnancy, adnexal masses are being encountered with greater frequency. Most of the time such masses are asymptomatic. It can be discovered in an emergency. Surgical intervention may cause risks to the mother and her fetus, while observation without intervention may also lead to unfavorable complications, such as ovarian torsion or the development of a tumor. Therefore, the management requires a balance between the maternal and fetal risks. We report two cases of torsion of adnexal masses during pregnancy, and we provide a brief literature review on the management and prognosis of this condition in pregnancy.

Torsion in the Gravid and Nongravid Uterus: A Review of the Literature of an Uncommon Diagnosis.

IMPORTANCE: Uterine torsion is an uncommon but life-threatening clinical situation that requires a high index of suspicion for diagnosis. OBJECTIVE: The aim of this study was to review literature and determine the etiology, presentation, diagnosis, and management of uterine torsion in the gravid and nongravid patients. EVIDENCE ACQUISITION: A literature search was undertaken by our research librarian using the search engines PubMed and CINAHL. The search terms used were "uterine torsion" OR (uterus and torsion). The search was limited to the English language, but the years searched were unlimited. RESULTS: The search identified 177 articles, 91 of which are the basis for this review. There have been 41 cases or gravid uterine torsion, their characteristics, and symptoms published since 2006. Torsion is rare in nongravid patients, but can still occur. CONCLUSION AND RELEVANCE: Uterine torsion is rare, can affect all ages, and can have significant implications for women. Prompt recognition allows for timely intervention and can mitigate harm.

The Protective Effects of Pulsed Magnetic Field and Melatonin on Testis Torsion and Detorsion Induced Rats Indicated by Scintigraphy, Positron Emission Tomography/Computed Tomography and Histopathological Methods.

PURPOSE: The aim of the present study was to show the protective effect of pulsed magnetic field (PMF) application and melatonin administration on damage in testis in a one-sided torsion detorsion induced rat model using testicular scintigraphy with 99mTc pertechnetate, PET/CT with 18F-FDG and histopathological methods. MATERIALS AND METHODS: Sixty male rats were used in the study; 30 rats were randomly divided into five groups for one day applications of sham control, torsion, melatonin, pulsed magnetic field (PMF) and melatonin plus PMF. Similarly, for one week group, the other 30 rats were divided into the same five group (n=6), but the animals were sacrificed after one week. Rats were exposed to 50 Hz, 1 mT PMF for two hours. PET/CT with 37 MBq 18F-FDG and testicular scintigraphy with and 37 MBq 99mTc pertechnetate examinations were carried out, and testicular tissue was examined using histopathological methods.  Results: In one day treatment, melatonin administration significantly increased perfusion and glucose metabolism compared to torsion group (p<0.01). Perfusion and glucose metabolism was also higher in the PMF and melatonin plus PMF groups than torsion group (p<0.01). In one week treatment, melatonin administration resulted in a significant higher perfusion rate and glucose metabolism rate compared to torsion group (p<0.01 and p<0.001, respectively). In addition, perfusion and glucose metabolism significantly increased in PMF and melatonin plus PMF groups compared to torsion group (p<0.01 and p<0.001, respectively). Furthermore, caspase-3 immunoreactivity and pathological changes increased in the torsion group (p<0.05). Melatonin and melatonin plus PMF treatment reduced the rate of immunoreactivity and pathological findings compared to the torsion group (p<0.05). CONCLUSION: According to these results it can be concluded that PMF application had a therapeutic benefit as effective as melatonin administering. In addition, it was indicated that PET/CT with 18F-FDG and testicular scintigraphy with 99mTc pertechnetate could be efficiently used in determining the treatment efficiency in testicular torsion.

Effect of Pregnancy on the Management and Outcomes of Ovarian Torsion: A Population-Based Matched Cohort Study.

STUDY OBJECTIVE: To compare the treatment and surgical outcomes of ovarian torsion in pregnant and nonpregnant women. DESIGN: A population-based matched cohort study (Canadian Task Force classification II.1). SETTING: The United States Health Care Cost and Utilization Project Nationwide Inpatient Sample from 2003 to 2011. PATIENTS: All cases of ovarian torsion among pregnant women and nonpregnant women with ovarian torsion (matched by age in a ratio of 1:1). INTERVENTIONS: Outcomes of interest included the type of treatment received for ovarian torsion and the complications of surgery. MEASUREMENTS AND MAIN RESULTS: There were 1366 women diagnosed with ovarian torsion among 8 532 163 pregnant women for an incidence of 1.6 in 10 000. Surgery was the predominant treatment, with laparotomy being more commonly performed on pregnant women versus nonpregnant women (57.0% vs 51.0%; odds ratio = 1.28; 95% confidence interval, 1.08-1.51; p < .01). Overall conservative management was less likely performed; however, it was more common among pregnant women versus nonpregnant women (odds ratio = 1.85; 95% confidence interval, 1.44-2.37; p < .01). In general, adverse events were uncommon in both groups although ovarian infarction was more commonly reported among nonpregnant women. CONCLUSION: The diagnosis of ovarian torsion in pregnancy is rare. Compared with nonpregnant women, laparotomy and conservative management are more common among pregnant women. Treatment of ovarian torsion in pregnancy has comparable outcomes with treatment in nonpregnant women.

Avaliação da resistência torcional em instrumentos endodônticos Protaper Next, WaveOne e WaveOne Gold após uso único / Assessment of torsional resistance of Protaper Next, WaveOne and WaveOne Gold instruments after single use

Os instrumentos endodônticos de NiTi passam por contínuas modificações em suas características com o intuito de otimizar a instrumentação em agilidade, simplificação de técnicas e segurança clínica. Este trabalho teve como objetivo avaliar a resistência torcional de instrumentos: Protaper Next X1 (X1), Protaper Next X2 (X2), WaveOne Primary (WO) e WaveOne Gold Primary (WOG) antes e após o uso único em dentes extraídos, bem como analisar a influência das diferentes características de fabricação neste comportamento. Foi realizada a caracterização geométrica dos instrumentos através da mensuração do diâmetro e área da seção transversal a 3mm da ponta. A caracterização estrutural, para identificar as fases presentes nos instrumentos foi realizada por difratometria de raios-X (DRX). Os instrumentos foram divididos em grupo controle (GC) e grupo experimental (GE) cada grupo contendo sete (n=7) instrumentos de cada tipo. Para o GC, instrumentos novos foram ensaiados até a ruptura, em dispositivo de torção de acordo com a norma ISO 3630-1, para análise da resistência torcional antes do uso. Instrumentos do GE realizaram a formatação de dois canais mesias de um molar inferior cada, exceto instrumentos X1 e X2 que foram utilizados em sequência, nos mesmos dentes. Os instrumentos do GE tiveram sua superfície analisada por microscopia eletrônica de varredura (MEV) após o uso, a fim de se avaliar a presença de trincas decorrentes da instrumentação. Posteriormente foram ensaiados no mesmo dispositivo de torção até a ruptura. A análise estatística dos valores médios de torque máximo para os diferentes sistemas de instrumentos foi realizada através do teste ANOVA, considerando como significativo um valor de p<0.05. A resistência torcional foi maior para o sistema WO, seguido por WOG e Protaper Next X2 e X1. Estes valores sugerem uma relação direta com as características geométricas encontradas nestes instrumentos, uma vez que variam de forma crescente de acordo com o diâmetro real e área da seção transversal a 3mm da ponta. A análise da resistência torcional não mostrou diferenças estatisticamente significativas em valores de torque antes e após o uso simulado. Nas imagens de MEV não foram visualizadas trincas longitudinais decorrentes de fadiga torcional, nem aquelas transversais causadas pelo carregamento cíclico da fadiga flexural. Desta forma, concluiu- se que, independente se para instrumentos reciprocantes ou rotatórios, de uso único preconizado ou não, a formatação dos dois canais mesiais de um molar não demostrou comprometer a resistência torcional dos instrumentos nem levar à nucleação de trincas que pudessem ser visualizadas em MEV

NiTi instruments undergo continuous modofications to improve their performance on shaping canals. This study aimed to assess the torsional resistance among instruments: Protaper Next (X1), Protaper Next X2 (X2), WaveOne Primary (WO) e WaveOne Gold Primary (WOG) before and after use in extracted teeth and the influence of manufacturing characteristics on this behavior. The geometric characterization was performed by measure of diameter and cross-sectional are at 3mm from the tip...

[Skret sieci wiekszej jako przyczyna dolegliwosci bólowych miednicy mniejszej u pacjentki po cieciu cesarskim - trudnosci diagnostyczne]. / Skret sieci wiekszej jako przyczyna dolegliwosci bólowych miednicy mniejszej u pacjentki po cieciu cesarskim - trudnosci diagnostyczne

Spontaneous torsion of the greater omentum is a rare cause of the acute abdomen or pain complaints of the pelvis minor. It can imitate an severe inflammatory conditions rolling in the peritoneal cavity like e.g. appendicitis. At the work a case of omental torsion at the patient after the caesarean section with pain problems in the right iliac fossa was presented. Problems of the preoperative diagnostic testing and a possible differential diagnosis were discussed.

Is It Ovarian Torsion? A Systematic Literature Review and Evaluation of Prediction Signs.

OBJECTIVES: This study aimed to identify, through systematic literature review, the most reliable clinical, biological, and radiological signs of ovarian torsion in the pediatric population and to compare their diagnostic value. METHODS: This is a systematic review of the literature, searching MEDLINE, EMBASE, and Cochrane Databases for articles published between January 1990 and January 2014. RESULTS: From the 946 references initially identified, 14 retrospective publications fulfilled the inclusion criteria, involving a total of 663 episodes of ovarian torsion. Sudden onset abdominal pain with nausea and/or vomiting is the most frequent symptom of ovarian torsion. It can occur at any age, not only in menarchal or perimenarchal patients. Abdominal tenderness is present in 88.4% of patients, whereas only 24% have a palpable mass. Blood tests are commonly requested (51.4% of cases) but are not diagnostic. Abnormalities on plain abdominal radiograph include masses, calcifications, and ossified images. Ultrasound has a sensitivity for ovarian torsion of 79% and computerized tomographic scan of 42.2%. There is a significant diagnostic delay at 101.8 hours (median). CONCLUSIONS: Abdominal pain in children and adolescents is difficult to evaluate, and the diagnosis of ovarian torsion remains a challenge. Because of its potential complications, we need effective clinical tools. From our review of the literature, it was not possible to develop a diagnostic algorithm. Further research is needed to improve our practice and shorten the delay to diagnosis. Considering the low incidence of ovarian torsion, a multicenter prospective study would be required.

Mare and foal survival and subsequent fertility of mares treated for uterine torsion.

REASONS FOR PERFORMING STUDY: Previous surveys have reported that mare and foal survival after correction of uterine torsion (UT) varies from 60 to 84% and from 30 to 54%, respectively. Furthermore, resolution via a standing flank laparotomy (SFL) has been associated with better foal, but not mare, survival. OBJECTIVES: To compare the success of SFL with other correction methods (e.g. midline or flank laparotomy under general anaesthesia; correction per vaginam). STUDY DESIGN: Retrospective analysis of clinical records. METHODS: Data on correction technique, stage of gestation, degree of rotation, survival and subsequent fertility for 189 mares treated for UT at 3 equine referral hospitals in The Netherlands during 1987-2007 were analysed. RESULTS: Mean stage of gestation at diagnosis was 283 days (range 153-369 days), with the majority of UTs (77.5%) occurring before Day 320 of gestation. After correction of UT, 90.5% of mares and 82.3% of foals survived to hospital discharge, between 3 and 39 days later, and to foaling. Multivariable logistic regression indicated that correction method and stage of gestation at UT affected survival of foals and mares. For foals, survival was 88.7% after SFL compared with 35.0% after other methods (P = 0.001). When UT occurred at <320 days, 90.6% of foals survived, compared with 56.1% at ≥320 days (P = 0.007). For mare survival, an interaction between stage of gestation and correction method was detected (P = 0.02), with higher survival after SFL (97.1%) than other methods (50.0%) at <320 days of gestation (P<0.01). When UT occurred at ≥320 days, mare survival did not differ between techniques (76.0 vs. 68.8%; P = 0.6). Of 123 mares that were bred again, 93.5% became pregnant; fertility did not differ between mares treated by SFL (93.9%) and other techniques (87.5%; P = 0.9). CONCLUSIONS: Standing flank laparotomy is the surgical technique of choice for resolving uncomplicated equine UT (i.e. with no coexisting gastrointestinal lesions) except when the stage of gestation exceeds 320 days.

Best practice in management of paediatric and adolescent hydrosalpinges: a systematic review.

BACKGROUND: Hydrosalpinx is a rare cause of abdominal pain in paediatric patients, though cases are documented in the literature. Its aetiology differs considerably from traditional hydrosalpinx due to ascending sexually transmitted infection. Hydrosalpinx can present mimicking an acute abdomen or can be asymptomatic. Management of paediatric hydrosalpinx varies, but often involves surgical removal of the affected tube. METHODS: In June 2015, a literature search using relevant keywords was completed on MEDLINE and EMBASE databases to determine best management of paediatric hydrosalpinx. RESULTS: We found 66 cases from 38 articles. Surgical intervention took place in 74% of cases (n=49). The most common surgical intervention was salpingectomy. In 3% of cases (n=2), nonsurgical medical management with hormonal therapy was utilized, with post-operative improvement in symptomology. In 23% of cases (n=15), conservative management was utilized: 2 of these cases torted, 4 cases persisted and 9 cases resolved. CONCLUSION: Overall, the results of this review demonstrate that there are comparable outcomes between surgical, medical and conservative management. However, medical and conservative management was not often offered, and more research is needed on the subject.

The effect of hypothermia on adnexal torsion/detorsion injury in a rat ovary model.

PURPOSE: Much attention has been given to hypothermia as it is effective in inhibiting inflammatory responses and also ischemia/reperfusion injury. Therefore, the aim of this study was to evaluate the effect of hypothermia on torsion/detorsion injury in rats. METHODS: Twenty-eight rats were randomly divided into four groups of sham-operated (SG), adnexal torsion/detorsion group (TG), adnexal torsion/detorsion+hypothermia group (THG) and hypothermia group (HG). In the SG group, right ovaries were excised after 3-h fixation to abdominal wall. In the TG, right adnexal underwent 720° torsion in a counterclockwise direction for 3h and then excised after 3-h detorsion period. In the THG, after 3-h torsion period, ovaries were immediately subjected to hypothermia (4°C) for 30-min and they were excised after 3-h detorsioned period. In the HG, the right ovaries were subjected to hypothermia for 30-min and excised after 3-h fixation period. One half of each ovary was immediately stored for antioxidant enzyme activity and tissue lipid peroxidation. The remainder was fixed for histopathological examination. RESULTS: Adnexal torsion and detorsion significantly increased the tissue level of Malondialdehyde, Superoxide dismutase and Reduced glutathione. On the other hand, hypothermia significantly reduced these oxidative stress parameters. The histopathological changes were less in the THG group; these changes were not statistically different from the other groups. CONCLUSION: The results of this study suggested that hypothermia inhibited the production of oxidative stress in the ovaries subjected to torsion/detorsion injury.

Adnexal masses in pregnancy.

With the advent of routine obstetrical ultrasound, the diagnosis of an adnexal mass in pregnancy has become increasingly common. Although the reported incidence and expected clinical course varies based on the gestational age at the time of diagnosis and the criteria used to define an adnexal mass, the majority of adnexal masses diagnosed in pregnancy are benign and are likely to resolve without complication or intervention. This review will discuss the epidemiology of adnexal masses in pregnancy, diagnostic tools, potential complications, and management options during pregnancy.

Adolescent Gynecologic Emergencies.

Adolescent females frequently present to the ED with complaints that may be caused by a gynecologic emergency. Differentiating and excluding some of the common and most serious gynecologic emergencies reviewed in this article are critical. Timely and effective treatment of these conditions, once diagnosed, can result in better health outcomes.

[Uterine torsion in cattle--therapy and consequences for calf and cow]. / Torsio uteri beim Rind--Therapie und Folgen für das Kalb und die Kuh.

AIM: To summarize the available literature on the therapy of uterine torsion in cattle and the consequences for cow and calf. MATERIAL AND METHODS: Analysis of the literature using electronic libraries (PubMed, Medline), German veterinary medical journals and obstetrical textbooks. RESULTS: The therapy includes the attempt to rotate the uterus back into its physiological position. Direct and indirect methods of retorsion are available and applied according to the case conditions. Subsequently, the extraction of the calf can be performed via vaginal delivery or caesarean section. The presence of uterine torsion always leads to dystocia. Following a successful retorsion, the time and degree of uterine torsion strongly influence the progress of the birth. The prognosis also depends on the aforementioned factors and varies between good to unsuccessful. The vitality of the calf displays great variation depending on the literature (14-90%), however, is generally greater under field than clinical conditions. Focussing on the puerperal development of the cow, all grades from mild irritations of the uterine involution to fatal complications occur. The influence on fertility depends on the progress of the birth and existing secondary complications. The risk for electrolyte disturbances is increased (approximately 50%) as is the risk of birth-associated injuries (approximately 20%). The incidence of placental retention varies widely between different authors (3-52%).

Does gradual detorsion protect the ovary against ischemia-reperfusion injury in rats?

AIM: Adnexal torsion is an infrequent and serious gynecologic surgical emergency. Adnexal torsion may result from pre-existing tubal or ovarian pathology or hyperstimulation of the ovary during ovulation. Early diagnosis and emergency surgical treatment (detorsion) are important to preserve fertility and to prevent peritonitis or loss of the adnexa. However, during reperfusion, tissue damage is more severe than during ischemia because of oxygen-derived radicals. The present study aimed to investigate the protective effect of gradual detorsion on adnexal torsion. MATERIALS AND METHODS: Twenty-one adult female rats were divided into three groups as sham-operated (Sh group, n = 7); torsion + detorsion (TD group, n = 7); and torsion + gradual detorsion (TGD group, n = 7). A midline laparotomy was performed under anesthesia. In the TD and TGD groups, the left adnexa along with tubal and ovarian vessels were twisted three times in a clockwise direction and fixed to the abdominal wall. After 30 h, detorsion was performed on the mesenteries of both TD and TGD groups. In the TGD group, however, detorsion was performed gradually: the ovarian mesentery was detorsioned 360°, followed by a 5-min pause, then a repeat of the cycle until full detorsion was achieved. Rats were killed 1 week later. Left ovaries were removed and evaluated histopathologically. RESULTS: The histopathological mean grade was significantly higher in the TD than in the TGD group (p < 0.05). CONCLUSION: Gradual detorsion can reduce reperfusion injury in a rat model of ovarian torsion. This method is easily applicable and may be a useful method for human patients with ovarian torsion.

Left ventricular torsion abnormalities in septic shock and corrective effect of volume loading: a pilot study.

BACKGROUND: Ventricular torsion is an important component of cardiac function. The effect of septic shock on left ventricular torsion is not known. Because torsion is influenced by changes in preload, we compared the effect of fluid loading on left ventricular torsion in septic shock with the response in matched healthy control subjects. METHODS: We assessed left ventricular torsion parameters using transthoracic echocardiography in 11 patients during early septic shock and in 11 age- and sex-matched healthy volunteers before and after rapid volume loading with 250 mL of a Ringer's lactate solution. RESULTS: Peak torsion and peak apical rotation were reduced in septic shock (10.2 ± 5.2° and 5.6 ± 5.4°) compared with healthy volunteers (16.3 ± 4.5° and 9.6 ± 1.5°; P = 0.009 and P = 0.006 respectively). Basal rotation was delayed and diastolic untwisting velocity reached its maximum later during diastole in septic shock patients than in healthy volunteers (104 ± 16% vs 111 ± 14% and 13 ± 5% vs 21 ± 10%; P = 0.03 and P = 0.034, respectively). Fluid challenge increased peak torsion in both groups (septic shock, 10.2 ± 5.3° vs 12.6 ± 3.9°; healthy volunteers, 16.3 ± 4.5° vs 18.1 ± 6°; P = 0.01). Fluid challenge increased left ventricular stroke volume in septic shock patients (P = 0.003). CONCLUSIONS: Compared with healthy volunteers, left ventricular torsion is impaired in septic shock patients. Fluid loading attenuates torsion abnormalities in parallel with increasing stroke volume. Reduced torsional motion might constitute a relevant component of septic cardiomyopathy, a notion that merits further testing in larger populations.

Protective effect of infliximab on ischemia/reperfusion injury in a rat ovary model: biochemical and histopathologic evaluation.

OBJECTIVE: The aim of this study was to investigate the effect of infliximab on experimentally induced ovarian ischemia/reperfusion injury (IRi). STUDY DESIGN: A total of 42 female rats were equally divided into 6 experimental groups; group 1: sham operation, group 2: 3-h ischemia, group 3 and 4: 3-h ischemia, 3-h reperfusion, group 5 and 6: 3-h ischemia, 24h reperfusion. In group 4 and group 6, 30 min before reperfusion, infliximab was administered intraperitoneally at a dose of 5mg/kg. Bilateral ovaries were removed for histopathologic and biochemical analysis. Serum MDA (sMDA), tissue MDA (tMDA), serum NO (sNO), tissue NO (tNO) and serum catalase concentrations were analyzed. Tissue damage of ovarian tissue was scored by histological examination. RESULTS: The infliximab administration significantly lowered the sNO, tNO and sMDA concentrations in group 4 compared to group 3 (p=0.041, p=0.025 and p=0.035, respectively). sNO, tNO and sMDA concentrations were also lower in group 6 when compared to group 5, but this differences were not significant (p>0.05). On the other hand, tMDA concentrations were lower in infliximab-applied groups when compared to ischemia/reperfusion groups (group 3 vs. 4 and 5 vs. 6) (p=0.045 and p=0.048, respectively). Moreover, histopathologic tissue damage scores in infliximab administration groups were significantly lower than in ischemia/reperfusion groups (p<0.001). CONCLUSION: Infliximab attenuates I/R-induced ovarian tissue injury in rats subjected to ischemia/reperfusion.

Clinical utility and assessment of cyclodeviation.

PURPOSE OF REVIEW: This article reviews and updates basic concepts, diagnosis and treatment of cyclotorsion. RECENT FINDINGS: Cyclodeviation in congenital superior oblique palsy (SOP) seems to correlate with the extent of superior oblique muscle hypoplasia. Genetic polymorphisms such as PHOX2B polymorphism, considered to be risk factors for congenital fibrosis of the extraocular muscles, may play a role in SOP and consequently in cyclotorsion. Two components of the ocular tilt reaction, ocular torsion and tilt of subjective visual vertical, seem to share similar sites of impairment in the brainstem. Harada-Ito surgery continues to be the procedure of choice in patients with isolated cyclodeviation, evidencing better outcome if less than 10° of preoperative excyclotorsion and preoperative fusion exist. Ocular torsion is not infrequent in patients with intermittent exotropia, especially in the most exo-deviated eye, emphasizing a possible role in pathogenesis. A new device for the assessment of dynamic torsion during ocular counter roll response using after-image has been described. Similarly, a new method to measure objective ocular torsion using retinal arcade tilt as a reference has been proposed. Finally, torsional data transformation such as the sum of angles of excyclodeviation, rather than using the angle of excyclodeviation of the paretic eye, is becoming increasingly popular among studies on torsion. SUMMARY: Exciting developments on ocular torsion have been described recently, and new ways to access and interpret ocular torsion have been devised as well.