Endometriosis diagnosis and staging by operating surgeon and expert review using multiple diagnostic tools: an inter-rater agreement study.

OBJECTIVE: To determine agreement on endometriosis diagnosis between real-time laparoscopy and subsequent expert review of digital images, operative reports, magnetic resonance imaging (MRI), and histopathology, viewed sequentially. DESIGN: Inter-rater agreement study. SETTING: Five urban surgical centres. POPULATION: Women, aged 18-44 years, who underwent a laparoscopy regardless of clinical indication. A random sample of 105 women with and 43 women without a postoperative endometriosis diagnosis was obtained from the ENDO study. METHODS: Laparoscopies were diagnosed, digitally recorded, and reassessed. MAIN OUTCOME MEASURES: Inter-observer agreement of endometriosis diagnosis and staging according to the revised American Society for Reproductive Medicine criteria. Prevalence and bias-adjusted kappa values (κ) were calculated for diagnosis, and weighted κ values were calculated for staging. RESULTS: Surgeons and expert reviewers had substantial agreement on diagnosis and staging after viewing digital images (n = 148; mean κ = 0.67, range 0.61-0.69; mean κ = 0.64, range 0.53-0.78, respectively) and after additionally viewing operative reports (n = 148; mean κ = 0.88, range 0.85-0.89; mean κ = 0.85, range 0.84-0.86, respectively). Although additionally viewing MRI findings (n = 36) did not greatly impact agreement, agreement substantially decreased after viewing histological findings (n = 67), with expert reviewers changing their assessment from a positive to a negative diagnosis in up to 20% of cases. CONCLUSION: Although these findings suggest that misclassification bias in the diagnosis or staging of endometriosis via visualised disease is minimal, they should alert gynaecologists who review operative images in order to make decisions on endometriosis treatment that operative reports/drawings and histopathology, but not necessarily MRI, will improve their ability to make sound judgments. TWEETABLE ABSTRACT: Endometriosis diagnosis and staging agreement between expert reviewers and operating surgeons was substantial.

Maternal and neonatal outcomes for pregnancies before and after gastric bypass surgery.

BACKGROUND: Interaction between maternal obesity, intrauterine environment and adverse clinical outcomes of newborns has been described. METHODS: Using statewide birth certificate data, this retrospective, matched-control cohort study compared paired birth weights and complications of infants born to women before and after Roux-en-Y gastric bypass surgery (RYGB) and to matched obese non-operated women in several different groups. Women who had given birth to a child before and after RYGB (group 1; n=295 matches) and women with pregnancies after RYGB (group 2; n=764 matches) were matched to non-operated women based on age, body mass index (BMI) prior to both pregnancy and RYGB, mother's race, year of mother/s birth, date of infant births and birth order. In addition, birth weights of 13 143 live births before and/or after RYGB of their mothers (n=5819) were compared (group 3). RESULTS: Odds ratios (ORs) for having a large-for-gestational-age (LGA) neonate were significantly less after RYGB than for non-surgical mothers: ORs for groups 1 and 2 were 0.19 (0.08-0.38) and 0.33 (0.21-0.51), respectively. In contrast, ORs in all three groups for risk of having a small for gestational age (SGA) neonate were greater for RYGB mothers compared to non-surgical mothers (ORs were 2.16 (1.00-5.04); 2.16 (1.43-3.32); and 2.25 (1.89-2.69), respectively). Neonatal complications were not different for group 1 RYGB and non-surgical women for the first pregnancy following RYGB. Pregnancy-induced hypertension and gestational diabetes were significantly lower for the first pregnancy of mothers following RYGB compared to matched pregnancies of non-surgical mothers. CONCLUSION: Women who had undergone RYGB not only had lower risk for having an LGA neonate compared to BMI-matched mothers, but also had significantly higher risk for delivering an SGA neonate following RYGB. RYGB women were less likely than non-operated women to have pregnancy-related hypertension and diabetes.

Pain typology and incident endometriosis.

STUDY QUESTION: What are the pain characteristics among women, with no prior endometriosis diagnosis, undergoing laparoscopy or laparotomy regardless of clinical indication? SUMMARY ANSWER: Women with surgically visualized endometriosis reported the highest chronic/cyclic pain and significantly greater dyspareunia, dysmenorrhea, and dyschezia compared with women with other gynecologic pathology (including uterine fibroids, pelvic adhesions, benign ovarian cysts, neoplasms and congenital Müllerian anomalies) or a normal pelvis. WHAT IS KNOWN ALREADY: Prior research has shown that various treatments for pain associated with endometriosis can be effective, making identification of specific pain characteristics in relation to endometriosis necessary for informing disease diagnosis and management. STUDY DESIGN, SIZE, DURATION: The study population for these analyses includes the ENDO Study (2007-2009) operative cohort: 473 women, ages 18-44 years, who underwent a diagnostic and/or therapeutic laparoscopy or laparotomy at one of 14 surgical centers located in Salt Lake City, UT or San Francisco, CA. Women with a history of surgically confirmed endometriosis were excluded. PARTICIPANTS/MATERIALS, SETTING AND METHODS: Endometriosis was defined as surgically visualized disease; staging was based on revised American Society for Reproductive Medicine (rASRM) criteria. All women completed a computer-assisted personal interview at baseline specifying 17 types of pain (rating severity via 11-point visual analog scale) and identifying any of 35 perineal and 60 full-body front and 60 full-body back sites for which they experienced pain in the last 6 months. MAIN RESULTS AND THE ROLE OF CHANCE: There was a high prevalence (≥30%) of chronic and cyclic pelvic pain reported by the entire study cohort regardless of post-operative diagnosis. However, women with a post-operative endometriosis diagnosis, compared with women diagnosed with other gynecologic disorders or a normal pelvis, reported more cyclic pelvic pain (49.5% versus 31.0% and 33.1%, P < 0.001). Additionally, women with endometriosis compared with women with a normal pelvis experienced more chronic pain (44.2 versus 30.2%, P = 0.04). Deep pain with intercourse, cramping with periods, and pain with bowel elimination were much more likely reported in women with versus without endometriosis (all P < 0.002). A higher percentage of women diagnosed with endometriosis compared with women with a normal pelvis reported vaginal (22.6 versus 10.3%, P < 0.01), right labial (18.4 versus 8.1%, P < 0.05) and left labial pain (15.3 versus 3.7%, P < 0.01) along with pain in the right/left hypogastric and umbilical abdominopelvic regions (P < 0.05 for all). Among women with endometriosis, no clear and consistent patterns emerged regarding pain characteristics and endometriosis staging or anatomic location. LIMITATIONS, REASONS FOR CAUTION: Interpretation of our findings requires caution given that we were limited in our assessment of pain characteristics by endometriosis staging and anatomic location due to the majority of women having minimal (stage I) disease (56%) and lesions in peritoneum-only location (51%). Significance tests for pain topology related to gynecologic pathology were not corrected for multiple comparisons. WIDER IMPLICATIONS OF THE FINDINGS: Results of our research suggest that while women with endometriosis appear to have higher pelvic pain, particularly dyspareunia, dysmenorrhea, dyschezia and pain in the vaginal and abdominopelvic area than women with other gynecologic disorders or a normal pelvis, pelvic pain is commonly reported among women undergoing laparoscopy, even among women with no identified gynecologic pathology. Future research should explore causes of pelvic pain among women who seek out gynecologic care but with no apparent gynecologic pathology. Given our and other's research showing little correlation between pelvic pain and rASRM staging among women with endometriosis, further development and use of a classification system that can better predict outcomes for endometriosis patients with pelvic pain for both surgical and nonsurgical treatment is needed. STUDY FUNDING/COMPETING INTERESTS: Supported by the Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development (contracts NO1-DK-6-3428, NO1-DK-6-3427, and 10001406-02). The authors have no potential competing interests.

A new molecular imprinted PEDOT glassy carbon electrode for carbamazepine detection.

An electrochemical sensor for the detection of carbamazepine was fabricated by the electropolymerization of PEDOT on glassy carbon electrodes. Molecular imprinted polymer sites were synthesized by cyclic voltammetry on the electrodes' surfaces providing high selectivity and sensitivity towards carbamazepine molecules. Scanning electron microscopy validated the formation of the polymer. Extraction of carbamazepine from the polymer was performed by immersion in acetonitrile and validated by ultraviolet-visible spectroscopy along with cyclic voltammetry experiments comparing pre- and post-template extraction data. Further cyclic voltammetry and square-wave voltammetry tests aided in characterizing the electrodes' response to carbamazepine concentration in PBS solution with [Fe(CN)6]3-/4- as a redox pair/mediator. The limits of detection and quantification were found to be 0.98 x 10-3 M and 2.97 x 10-3 M respectively. The biosensor was highly sensitive to carbamazepine molecules in comparison to non-imprinted electrodes, simple to construct and easy to operate.

Technique for replacing the mitral valve with a pulmonary autograft: the Ross-Kabbani operation.

Replacing the mitral valve with a pulmonary autograft is an important option at the disposal of surgeons working in areas where lifelong anticoagulation is impractical. In this article we describe the technique of this operation as it has evolved through our experience with 51 patients operated on since July 1997.

The mitral pulmonary autograft: a follow up cautionary report.

BACKGROUND AND AIM OF THE STUDY: The study aim was to alert surgeons embarking on mitral replacement with the pulmonary autograft to the possibility of graft stenosis resulting from kinking of the Dacron tube support. METHODS AND RESULTS: After having used old-style Dacron tubing for pulmonary autograft support in 32 patients, a change was made to a softer variety. This, together with routine retention of the posterior subvalvular apparatus, resulted in Dacron tube angulation and autograft stenosis detected at intraoperative echocardiography in four consecutive patients, This sequela was corrected in one patient by re-adjusting the pericardial collar, and in another by severing the retained chordae. However, in two patients it was necessary to sacrifice the autograft and replace it with a mechanical prosthesis. When the reason for the complication was identified, and a return to the use of a firmer Dacron material instigated, this phenomenon disappeared and surgery was completed in the final three patients, without mishap. CONCLUSION: The use of a newer soft Dacron tubing to support the pulmonary autograft in mitral replacement might result in autograft stenosis. Thus, a firm-type Dacron should be used for this operation.

Mitral valve replacement with a pulmonary autograft: initial experience.

BACKGROUND AND AIM OF THE STUDY: For long-term substitution of the mitral valve, mechanical prostheses require life-long anticoagulation which is impractical in developing countries, xenografts degenerate early in our young population, and mitral homografts have not yet been established as being suitable. We therefore returned to an original concept first reported by one of the authors (D.N.R.) in 1967. METHODS: Between July 1997 and November 1998, 22 patients (mean age 40.3 years; range: 28 to 57 years) with rheumatic mitral valve disease unsuitable for reconstruction were subjected to excision of their pulmonary valve in the standard fashion of the Ross procedure. The inverted autograft was incorporated in a 2.5 cm-long Dacron conduit, with a pericardial collar attached to its proximal end. The distal end of the autograft-conduit was sutured to the annulus of the excised mitral valve, and the proximal end incorporating the pericardial collar was attached to the adjacent atrial wall. In this way all prosthetic material was covered. The right ventricular outflow was reconstructed with a pulmonary homograft in 17 patients, with an aortic homograft in two, and with a porcine pulmonary xenograft in three. RESULTS: One patient developed a fatal cerebrovascular accident, probably related to an incorrectly placed pericardial collar with rough surface exposed to the blood flow. In a second patient the autograft had to be replaced six weeks after operation due to bacterial endocarditis contracted in the operating room. Echocardiography confirmed excellent function of the remaining autografts up to 16 months postoperatively (mean follow up 8.3 months). CONCLUSIONS: We believe the pulmonary autograft to be a valid option for mitral valve replacement in our patients.

Use of the pulmonary autograft for mitral replacement: short- and medium-term experience.

OBJECTIVES: In an effort to find a suitable mitral substitute for our young rheumatic patients who cannot follow a proper anticoagulation regimen for life, we resorted to an old concept reported by one of the authors (D.N.R.) in 1967. This report summarizes our experience with the Ross-mitral operation to date. METHODS: Between 19 June 1997 and 27 June 2000, 43 patients with rheumatic valve disease underwent the Ross-mitral operation. Two patients were excluded because of graft stenosis detected at the end of the procedure for which the autograft had to be sacrificed. Of the remaining 41 patients 29 were female, and the age range was 12--57 years (median 39 years). The autograft was incorporated within a Dacron tubing, with a pericardial collar attached to its proximal end. The conduit was sutured distally to the excised mitral annulus; the pericardium was attached proximally to the atrial wall in 36 patients, and was used simply to cover the Dacron tubing in five patients. The pulmonary artery was replaced with a pulmonary or aortic homograft, or with a pulmonary xenograft. RESULTS: There were two hospital fatalities from a cerebrovascular accident and a lung injury, and two postoperative myocardial infarctions. There were five late deaths, two due to bacterial endocarditis, one due to excessive bleeding at reoperation for a paravalvular leak, and two not related to the procedure. A phenomenon of 'autograft stenosis' occurred intraoperatively in four recent consecutive patients that probably resulted from our use, for the first time, of softer Dacron tubing material. This was repaired in two of the four patients. Echocardiography confirmed excellent functioning of all 34 autografts of surviving patients up to 36 months postoperatively (mean follow-up 18.2 months). Two patients remain in functional Class III status, one due to left heart failure following myocardial infarction, and the other due to recurrent tricuspid insufficiency. CONCLUSIONS: We believe that the mitral pulmonary autograft is a worthwhile alternative to mechanical prostheses in developing countries.

The effect of gestational age on trial of labor after Cesarean section.

OBJECTIVES: To evaluate the effect of gestational age on the rate of successful vaginal delivery and the rate of uterine rupture in patients undergoing a trial of labor (TOL) after a prior Cesarean delivery. STUDY DESIGN: This was a cohort study including patients with a live singleton fetus undergoing a TOL after a previous low transverse Cesarean delivery between 1988 and 2002. Patients were divided into three groups according to gestational age: 24-36 weeks 6 days, 37-40 weeks 6 days and > or = 41 weeks. Obstetric outcomes, including the rates of successful vaginal delivery and symptomatic uterine rupture, were compared between the groups. Multivariate logistic regression analysis was performed to adjust for potential confounding factors. RESULTS: There were 253, 1911 and 329 patients in each group, respectively. In patients with advanced gestational age (> or = 41 weeks) the rate of uterine rupture was significantly higher (0% vs. 1.0% vs. 2.7%, p = 0.006) and the rate of successful vaginal deliveries was significantly lower (83% vs. 76.9% vs. 62.6%, p < 0.001). After adjusting for confounding variables, advanced gestational age was associated with a lower rate of successful vaginal delivery (odds ratio 0.68, 95% CI 0.51-0.89), and a higher rate of uterine rupture (odds ratio 2.85, 95% CI 1.27-6.42) when compared to 37-40 weeks 6 days. CONCLUSION: Advanced gestational age is associated with higher rates of failed TOL and uterine rupture.

Socio-demographic characteristics of the physically disabled in Canada.

The major purpose of this paper is to compare a large sample of physically disabled Canadians (N = 1,692) with a similar group of able-bodied persons on a set of socio-demographic characteristics. The data are obtained from the General Social Survey of 1985, and the findings are placed within a minority group status framework. A series of demographic, personal adjustment and economic variables are analyzed using both cross-tabular and logit statistical techniques. In general, the data show that the physically disabled are older, female, and more likely to be divorced, separated or widowed. Relative to the able-bodied, they are not satisfied with their health, jobs, economic circumstances, personal relationships, and life in general. The factors associated with dissatisfaction are likely to be primarily economic and personal. The data developed in this study provide evidence that the physically disabled in Canada are in fact a minority group who are disadvantaged and do not participate fully in the structure of Canadian society.

[Human brucellosis. Retrospective studies of 63 cases in Lebanon]. / Brucellose humaine. Etude rétrospective de 63 cas observés au Liban.

OBJECTIVES: We performed an epidemiological survey to ascertain the clinical features of brucellosis in Lebanon. PATIENTS AND METHODS: Between 1994 and 1998, 63 patients were seen at the Hôtel-Dieu de France Hospital in Beirut Lebanon. Diagnostic criteria were brucellar agglutinins at a titer > or = 1/160 with symptoms suggestive of brucellosis in the absence of another diagnosis. We also conducted a survey in 1138 cases registered by the Ministry of Health during the same period. RESULTS: Among the 1137 cases, 40% of the patients were over 60 and only 16% were under 14. The overall male to female ratio was 1.01 and 69% of the patients were seen in spring and summer. Among the 63 patients, 10 were pediatric cases. The disease was acute in 41 (65%), subacute in 21 (33%) and chronic in 1. The main presenting symptoms were fever, sweating, easy fatigability and joint pain. Osteoarticular involvement was the most prevalent complication (25%), predominantly spondylitis. Among the blood tests, relative lymphocytosis was significantly more frequent in children than adults (80% versus 13%, p < 0.001). CONCLUSION: Brucellosis is still an endemic disease in Lebanon and should be considered notably in patients presenting with prolonged fever, and articular and neurological manifestations.

The racial disparity in outcomes in endometrial cancer: could this be explained on a molecular level?

OBJECTIVE: The racial disparities among patients with endometrial carcinoma have been previously reported. The objective of this study is to analyze and compare the molecular profiles in endometrial cancer in Caucasian and African American patients using a number of known molecular markers. MATERIALS AND METHODS: 147 patients diagnosed with endometrial cancer between 1995 and 2001 were included in the study. Patients' demographics, clinical and pathological data were reviewed. Immunohistochemical staining for p53, VEGF, Ki-67 and HIF-1alpha was performed on tissue micro array sections. Tumors' expression of p53, VEGF, Ki-67, and HIF-1alpha was compared based on ethnicity and tumor type (Type I = endometrioid carcinomas and Type II = non-endometrioid carcinomas). Spearman's correlation and Fisher's Exact Tests were used for statistical analysis and Kaplan-Meier, log-rank and Cox regression were used for survival analysis. RESULTS: 97 patients were Caucasian and 50 patients were African American. The mean age was 62 (33-91) years for Caucasian patients and 63.5 (24-89) years for the African American patients. African American patients had more Type II carcinoma than Caucasian patients (P = 0.055). High p53 expression was statistically significant among the African American patients (49% vs. 30%, P = 0.035) versus Caucasian patients. There was no significant difference demonstrated when comparing the VEGF, Ki-67, and HIF-1alpha expression between the racial groups. Survival analysis showed a trend toward a shorter survival in the African American patients compared to the Caucasian patients; median survival 62 versus 77 months (P = 0.061). On the other hand, we did not find a significant difference in survival by ethnicity when we adjusted for tumor histology. CONCLUSION: While African American patients with endometrial cancer seem to show a trend toward a shorter survival, this seems to be mainly due to the fact that they have a higher proportion of Type II tumors. The molecular profiles for p53, Ki-67, VEGF and HIF-1alpha expression of histologically matched tumors were similar between the two ethnic groups.

A case of a large coronary artery fistula in an elderly patient surgically corrected 12 years after initial diagnosis.

This case report discusses the natural history of a large coronary artery fistula in an elderly patient treated conservatively for 12 years. There has been no previous report of long term follow-up in a patient with a large coronary artery fistula with symptoms of congestive heart failure. The surgical management and clinical response to surgical correction will be discussed, and an extensive review of the literature will be performed.

Image recovery from data acquired with a charge-coupled-device camera.

A model for data acquired with the use of a charge-coupled-device camera is given and is then used for developing a new iterative method for restoring intensities of objects observed with such a camera. The model includes the effects of point spread, photoconversion noise, readout noise, nonuniform flat-field response, nonuniform spectral response, and extraneous charge carriers resulting from bias, dark current, and both internal and external background radiation. An iterative algorithm is identified that produces a sequence of estimates converging toward a constrained maximum-likelihood estimate of the intensity distribution of an imaged object. An example is given for restoring images from data acquired with the use of the Hubble Space Telescope.

Electrophysiological and field activity of halogenated analogs of (E,E)-8,10-dodecadien-1-ol, the main pheromone component, in codling moth (Cydia pomonella L.).

Pest monitoring and control of the codling moth,Cydia pomonella L., have been developed using the main pheromone component of this species, (E,E)-8,10-dodecadienol (codlemone). However, the activity of codlemone is not satisfactory for pest control by mating disruption. Thus, we have synthesized halogenated analogs of codlemone to see if they could be used as new agents for pest control of the codling moth. Their biological activity was measured by electrophysiological techniques. In EAG screening, codlemone was the most active compound. F(10,11)-codlemone [(E,E)-10,11-difluoro-8,10-dodecadienol] and Cl-codlemone [(E,E)-11-chloro-8,10-undecadienol] elicited significant EAG responses, F(10,11)-codlemone triggering responses not significantly different from responses to codlemone. EAG cross-adaptation experiments and single sensillum recordings revealed that these compounds were detected by the same receptor neuron type as codlemone. No competitive inhibition with codlemone was observed from nonactive compounds. In field trapping, F(10,11)-codlemone and Cl-codlemone were more attractive to male codling moths than codlemone itself. Possible explanations of this activity are discussed.

Effects of sulfonamides on a metabolite-regulated ATPi-sensitive K+ channel in rat pancreatic B-cells.

Intracellular ATP (ATPi)-sensitive K+ [K+(ATP)] channels are now a recognized site of action of clinically useful hypoglycemic and hyperglycemic sulfonamides. We have further examined the action of these agents on single K+ channels in rat pancreatic B-cells 1) Tolbutamide and glyburide, two hypoglycemic sulfonylureas which decrease K+(ATP) channel activity in the cell-attached patch, affect the kinetics of K+(ATP) channel in a manner similar to glucose. They shorten the duration of the "burst," or cluster of open channel events, while lengthening the intervals between bursts. 2) The hyperglycemic vasodilator diazoxide increases mean K+(ATP) channel activity in the cell-attached patch as well as in the inside-out excised patch exposed to ATPi. It appears to lengthen channel bursts and shorten the intervals between them. Two structurally similar diuretics, hydrochlorothiazide and furosemide, which have mild hyperglycemic effects, do not increase K+(ATP) channel activity even at clinically toxic concentrations. 3) Neither the sulfonylureas nor diazoxide directly affect the activity of single delayed rectifier K+ channels or single calcium and voltage-activated K+ channels in normal B-cells.

Early experience with left ventricular volume reduction surgery in Syria.

OBJECTIVE: To review our early experience with left ventricular volume reduction surgery (the Batista operation) in the management of patients with end-stage heart failure. METHODS: Between December 1996 and April 1998, 10 patients (9 males, mean age 32yr) with advanced symptomatic cardiomyopathy underwent left ventricular volume reduction surgery at Damascus University Cardiovascular Surgical Center. The cause of cardiomyopathy was idiopathic in three patients, valvular in four, ischemic in two, and viral myocarditis in one patient. Concomitant procedures included aortic valve replacement in four patients, mitral valve repair in six patients, and coronary artery bypass grafting in two patients. RESULTS: All patients survived the procedure. Echocardiography prior to discharge documented significant improvement in ejection fraction in all but two patients. Mean follow-up was 7.6 months. After discharge, three patients developed progressive congestive heart failure to which they subsequently succumbed, and two more patients died suddenly late postoperatively. Only two patients continue to show both clinical and echocardiographic evidence of improvement. CONCLUSION: Left ventricular volume reduction surgery cannot be freely advocated until better means are found to identify patients who will benefit from the procedure, and proper prophylaxis against fatal postoperative complications can be afforded.