Vesicouterine fistula in pregnancy: a case report.

BACKGROUND: Vesicouterine fistula is a rare complication of Caesarean delivery. This is the third known report of vesicouterine fistula diagnosed during pregnancy. CASE: Linda (pseudonym), a 28-year-old woman in her second pregnancy, having had a Caesarean delivery in her first pregnancy, was admitted to the delivery unit with possible preterm ruptured membranes at 23 weeks' gestation. She also complained of a fluid-filled sac bulging from her introitus during her admission assessment. Diagnosis of premature rupture of membranes was confirmed by a positive nitrazine paper test and appearance of ferning during microscopic evaluation of vaginal fluid. Cystoscopy, performed 3 days after admission, demonstrated ballooning of amnion into the bladder. At 24 weeks' gestation, the woman had a precipitous vaginal breech delivery. Two months later, the fistula was successfully repaired through a transabdominal route. CONCLUSION: Although uncommon in pregnancy, vesicouterine fistula should be considered in women who present with urinary incontinence or recurrent urinary tract infections after a lower transverse Caesarean section. Evaluation in pregnancy is usually limited to cystoscopy. Treatment is usually surgical and is often delayed until 2 to 3 months following delivery.

Early events in ovarian epithelial carcinogenesis: progress and problems in experimental approaches.

The etiology and early events in the progression of epithelial ovarian carcinomas are among the least understood of all major human malignancies. There are no adequate means for early detection of these neoplasms and, as a result, they are usually diagnosed in late stages. The purpose of this review is to point out some of the peculiar problems and limitations that have hampered progress in ovarian carcinogenesis research and to summarize new approaches and recent advances in our understanding of this process. The review first presents an overview of the properties of the ovarian surface epithelium (OSE) which is thought to be the source of epithelial ovarian carcinomas, followed by a discussion of recent research based on human OSE. This includes sections on methodology for the attainment and study of OSE, investigations of OSE from women with predisposing mutations, and attempts to convert normal OSE to malignancy. This overview is followed by a discussion of the contributions, potential, and limitations of animal models. The knowledge gained by these approaches will likely lead to improvements in our ability to prevent, diagnose, and treat ovarian cancer.

Small-dose selective spinal anesthesia for short-duration outpatient laparoscopy: recovery characteristics compared with desflurane anesthesia.

UNLABELLED: We conducted a randomized controlled trial to compare the recovery characteristics of selective spinal anesthesia (SSA) and desflurane anesthesia (DES) in outpatient gynecological laparoscopy. Twenty ASA physical status I patients undergoing gynecological laparoscopy were randomized to receive either SSA with lidocaine 10 mg + sufentanil 10 microg or general anesthesia with DES and N(2)O. Intraoperative conditions, recovery times, postanesthesia recovery scores, and postoperative outcomes were recorded. Intraoperative conditions were comparable in both groups. All patients in the SSA group were awake and oriented at the end of surgery, whereas patients in the DES group required 7 +/- 2 min for extubation and orientation. SSA patients had a significantly shorter time to straight leg raising (3 +/- 1 min versus 9 +/- 4 min; P < 0.0001) and to ambulation (3 +/- 0.9 min versus 59 +/- 16 min; P < 0.0001) compared with the DES group. SSA patients had significantly less postoperative pain than DES patients (P < 0.05). We concluded that SSA was an effective alternative to DES for outpatient gynecological laparoscopy. IMPLICATIONS: This study compared the use of a desflurane general anesthetic to a small-dose spinal anesthetic in ambulatory gynecological laparoscopy. Using the spinal technique, patients can walk from the operating room table to a stretcher on completion of surgery. Their recovery time was similar to that of the desflurane group.

Small-dose selective spinal anaesthesia for short-duration outpatient gynaecological laparoscopy: recovery characteristics compared with propofol anaesthesia.

A randomized controlled trial compared recovery characteristics after selective spinal anaesthesia (SSA) or propofol general anaesthesia (GA) for short-duration outpatient laparoscopic surgery. Forty women were randomized to receive either SSA (1% lidocaine 10 mg, sufentanil 10 microg and sterile water 1.8 ml) or GA (propofol and nitrous oxide 50% in oxygen). Compared with the GA group, times to leaving the operating room, performing a straight leg raise, performing deep knee-bends and achieving an Aldrete score >9 and the time in Phase II recovery were significantly shorter (P < 0.05) in the SSA group.

Selective spinal anesthesia for outpatient laparoscopy. I: characteristics of three hypobaric solutions.

PURPOSE: To determine the characteristics and recovery profiles of three hypobaric spinal anesthetic solutions. METHODS: Thirty outpatients undergoing outpatient laparoscopy were randomly assigned to receive spinal anesthesia with one of three small-dose solutions. Group I--20 mg lidocaine plus 25 microg fentanyl; Group II--20 mg lidocaine plus 10 microg sufentanil; Group III--10 mg lidocaine plus 10 microg sufentanil. Solutions were diluted to three ml with sterile water for injection. A 27-gauge Whitacre needle was inserted at L2-3 or L3-4 in the sitting position. Sensory and motor recovery were assessed with pinprick, proprioception, light touch and a modified Bromage scale. RESULTS: Operating conditions were good to excellent in all three groups. The incidence of shoulder tip discomfort, pruritus and nausea was not significantly different between groups. Light touch was present in all three groups and proprioception was present in most patients during and after surgery. Group III patients had a more rapid recovery of pinprick analgesia and Group II patients had the slowest recovery of pinprick analgesia. Motor block recovery was comparable in the three groups. Eighty percent of patients in Groups III and I were able to perform 'deep knee bends' and 'straight leg raises' at the end of surgery. CONCLUSION: For short duration laparoscopy, spinal 10 mg lidocaine with 1O microg sufentanil provided selective pin prick analgesia, with preserved touch, proprioception and limited motor block. Operating conditions were satisfactory and most patients were able to fulfill 'walk out' criteria at the end of surgery.

Selective spinal anesthesia for outpatient laparoscopy. II: epinephrine and spinal cord function.

PURPOSE: To compare two small-dose solutions (with and without epinephrine) for spinal anesthesia during outpatient laparoscopy and to determine spinal cord function with these low-dose solutions. METHOD: Twenty outpatients undergoing gynecological laparoscopy were randomly assigned to receive spinal anesthesia with one of two low dose solutions. Group LS-10 mg lidocaine plus 10 microg sufentanil; Group LSE-10 mg lidocaine plus 10 microg sufentanil plus epinephrine 50 microg. Solutions were diluted to three millilitres with sterile water for injection. A 27-gauge Whitacre needle was inserted at L2-3 or L3-4 in the sitting position. Operating conditions and spinal cord function (spinothalamic, dorsal column and motor) were assessed. RESULTS: Operating conditions were good-excellent in both groups. The incidence of shoulder tip discomfort, pruritus and nausea, and the amount of supplementation with alfentanil and midazolam was not different between groups. Most patients in both groups had preserved dorsal column function and normal motor power on arrival in PACU and were able to satisfy 'walk out' criteria. Recovery of pinprick sensation and discharge times were not different. Mild pruritus (VAS score < or = 5) was present in both groups. CONCLUSION: For short duration laparoscopy, addition of 50 microg epinephrine to a small dose of spinal 10 mg lidocaine with 10 microg sufentanil did not provide additional benefit in terms of intraoperative analgesia or operating conditions. Spinal cord function was preserved with small-dose techniques.

Selective spinal anesthesia for outpatient laparoscopy. IV: population pharmacodynamic modelling.

PURPOSE: To apply a population pharmacodynamic model to small-dose hypobaric spinal anesthesia for outpatient laparoscopy. METHODS: The level of spinal analgesia after spinal blockade with small-dose (20-25 mg) hypobaric lidocaine was assessed by means of pinprick in patients undergoing outpatient laparoscopy. In 57 patients, 385 measurements were available for analysis. We first modelled the data for each patient with a mixed-effects model described by Schnider (Model 1). The population mean parameters, inter-individual variance, and residual variance were estimated. Clinically important endpoints (time to reach T10 (onset), time to maximal level, duration and maximally attained level) of each patient were calculated based on the estimated time course of analgesia level for each patient. The model was used to predict the later data with respect to level of spinal analgesia of each patient from fits based on the observed data in the first 75 min. RESULTS: The mean +/- SD onset time was 8.3 +/- 1.9 min, time to maximal level was 20.8 +/- 5.3 min, duration of effect was 37.9 +/- 13.1 min, and mean maximal level was T5. There was a good correlation (R2 = 0.90) between the observed levels of analgesia and those predicted from the model. Data from the first 75 min predicted the later observed data for each patient moderately well (R2 = 0.38). CONCLUSION: A population pharmacodynamic model was applied to low-dose hypobaric lidocaine spinal anesthesia. Clinically important endpoints were determined and forecasting of later data with respect to level of spinal analgesia was attempted. Such an approach may be useful in the management of low-dose spinal anesthetic techniques in outpatients.

Selective spinal anesthesia for outpatient laparoscopy. III: sufentanil vs lidocaine-sufentanil.

PURPOSE: The efficacy of low dose intrathecal lidocaine-sufentanil was compared with intrathecal sufentanil for short duration outpatient gynecological laparoscopy. METHODS: Thirteen ASA I and II patients undergoing gynecological laparoscopy were studied in a randomized double-blind trial. Patients received either intrathecal 10 mg lidocaine plus 10 microg sufentanil (Group LS) or intrathecal 20 microg sufentanil (Group S), each diluted to 3 mL with sterile water through a 27g Whitacre needle in the sitting position. Sensory and motor recovery were assessed with pinprick and a modified Bromage scale. RESULTS: One of seven Group LS patients and two of five Group S patients required conversion to general anesthesia for failed skin test with forceps. Two of the remaining three Group S patients felt sharpness with skin incision. The study was terminated early because of inadequate anesthesia in Group S. The small sample size (n = 9) made statistical analysis uninformative. CONCLUSION: Intrathecal 20 microg sufentanil is unsuitable as a sole agent for gynecological laparoscopy.

Selective spinal anesthesia for outpatient laparoscopy. V: pharmacoeconomic comparison vs general anesthesia.

PURPOSE: To compare the cost and effectiveness of small-dose spinal anesthesia (SP) with general anesthesia (GA) for outpatient laparoscopy. METHODS: A retrospective record analysis of 24 patients who received SP were compared with 28 patients who received GA in our Daycare centre. The costs of anesthesia and recovery were calculated, from an institutional perspective, using 1997 Canadian Dollar values. Effectiveness was measured in terms of time for anesthesia and recovery, and postoperative antiemetic and analgesic requirements. RESULTS: Both groups were well matched for age, weight, duration and type of surgery. The mean total cost for the SP group of $53.45 +/- 10.40 was no different from that for the GA group of $48.92 +/- 10.25 (95% CI -10.3, 1.2). Time to administer anesthesia was longer in the SP group with a mean time of 18 +/- 8 min compared with 10 +/- 3 min in the GA group (CI -11.3, -4.7). Recovery time in the PACU was longer in the SP group 123 +/- 51 min compared with 94 +/- 48 min (CI -56.6,-1.4). Postoperative antiemetic requirements were similar: 8% in SP group vs 14% in GA group, whereas analgesic requirements were less in the SP group with 25% receiving analgesia compared with 75% in the GA group (P < 0.05). CONCLUSION: The total cost of anesthesia and recovery using SP is similar to that for GA when used for outpatient laparoscopy. Spinal anesthesia was less effective than GA in time to administer anesthesia and in duration of recovery. Postoperative analgesic requirements were reduced using SP.

alphavbeta3 and vitronectin expression by normal ovarian surface epithelial cells: role in cell adhesion and cell proliferation.

The alphavbeta3 integrin and its ligand vitronectin are expressed by differentiated epithelial ovarian carcinomas and carcinoma cell lines in culture. Moreover, alphavbeta3/vitronectin interaction influences adhesion and migration of ovarian carcinoma cells in culture. For a better understanding of the behavior of these carcinomas, it appeared necessary to study the characteristics of their normal counterpart, the ovarian surface epithelium (OSE). The present study showed that normal cultured human OSE cells, like the carcinoma cells, have the ability to synthesize vitronectin. The vitronectin receptor, alphavbeta3 integrin, is also expressed by OSE cells and is localized in focal contacts close to paxillin, a focal contact-specific protein, and p125(FAK), a cytoskeletal and signaling molecule. This localization suggested an active participation of the integrin in the adhesion and/or proliferation of OSE cells. Indeed, the use of a blocking antibody demonstrated that alphav integrins promote OSE cell adhesion on vitronectin but not on fibronectin and that these integrins are required for maximal proliferative activity. The results suggest a role of the alphavbeta3/vitronectin system in normal OSE physiology and demonstrate that the expression of this system by well-differentiated ovarian carcinomas reflects the retention of normal cell properties.

Immunological effects of an arginine side chain contaminating synthetically prepared peptides.

The side chain, 4-methoxy-2,3,6-trimethylbenzenesulphonyl (Mtr), is a protective group coupled to arginine to mask the omega-nitrogen, in order to protect the guanidino function during peptide synthesis by the 9-fluorenylmethoxycarbonyl (Fmoc) procedure (Walker, 1994). This group is removed at the completion of peptide synthesis; however, the cleavage process can be incomplete. We have found that animals injected with a mixed population of pure, i.e. unmodified, and Mtr-containing MBP peptides have an immunodominant humoral response to the Mtr-bearing peptide. This response is dependent on the characteristics of the MBP peptide involved. For two MBP peptides, the Mtr-containing peptide had increased binding to antibody over pure peptide. For two other peptides, only the Mtr-containing peptide bound antibody while the unmodified peptide did not. In a separate system involving a polyclonal response to an unrelated peptide from beta2-microglobulin (beta2 m), the dominance of the Mtr group was also evident. These results provide further evidence that a small side chain on a single amino acid in a peptide can markedly alter the immunogenicity and antigenicity of that peptide for antibody reactivity. This evidence emphasizes the need for a critical awareness of each component of peptide synthesis and its potential to alter the immunoreactivity of the final product.

Small-dose hypobaric lidocaine-fentanyl spinal anesthesia for short duration outpatient laparoscopy. I. A randomized comparison with conventional dose hyperbaric lidocaine.

A randomized, single-blind trial of two spinal anesthetic solutions for outpatient laparoscopy was conducted to compare intraoperative conditions and postoperative recovery. Thirty women (ASA physical status I and II) were assigned to one of two groups. Group I patients received a small-dose hypobaric solution of 1% lidocaine 25 mg made up to 3 mL by the addition of fentanyl 25 micrograms. Group II patients received a conventional-dose hyperbaric solution of 5% lidocaine 75 mg (in 7.5% dextrose) made up to 3 mL by the addition of 1.5 mL 10% dextrose. All patients received 500 mL of crystalloid preloading. Spinal anesthesia was performed at L2-3 or L3-4 with a 27-gauge Quincke point needle. Surgery commenced when the level of sensory anesthesia reached T-6. Intraoperative hypotension requiring treatment with ephedrine occurred in 54% of Group II patients but not in any Group I patients. Median (range) time for full motor recovery was 50 (0-95) min in Group I patients compared to 90 (50-120) min in Group II patients (P = 0.0005). Sensory recovery also occurred faster in Group I patients (100 +/- 22 min) compared with Group II patients (140 +/- 27 min, P = 0.0001). Postoperative headache occurred in 38% of all patients and 70% of these were postural in nature. Oral analgesia was the only treatment required. Spinal anesthesia did not result in a significant incidence of postoperative backache. On follow-up, 96% said they found spinal needle insertion acceptable, 93% found surgery comfortable, and 90% said they would request spinal anesthesia for laparoscopy in future. Overall, this study found spinal anesthesia for outpatient laparoscopy to have high patient acceptance and a comparable complication rate to other studies. The small-dose hypobaric lidocaine-fentanyl technique has advantages over conventional-dose hyperbaric lidocaine of no hypotension and faster recovery.

Small-dose hypobaric lidocaine-fentanyl spinal anesthesia for short duration outpatient laparoscopy. II. Optimal fentanyl dose.

We performed a double-blind, controlled trial to determine the optimal dose of intrathecal fentanyl in small-dose hypobaric lidocaine spinal anesthesia for outpatient laparoscopy. Sixty-four gynecological patients were randomized into three groups, receiving 0, 10, or 25 micrograms fentanyl added to 20 mg lidocaine and sterile water (total 3 mL). Administration was with 27-gauge Whitacre needles and patients sat upright until the block was > T-8. One patient in the 0-microgram fentanyl group required general anesthesia 40 min after the start of surgery, leaving 21 patients per group. Three patients in each of the 0-microgram and 10-microgram fentanyl groups had mild discomfort with trocar insertion, or return of some sensation and felt discomfort or sutures toward the end of surgery. Shoulder-tip pain was less frequent in the 25-microgram than 0-microgram fentanyl group, 28% vs 67% (P < 0.0166). Intraoperative supplementation with alfentanil (+/- propofol) was needed less often in the 25-microgram than 0-microgram fentanyl group, 43% vs 76% (P = 0.028). Recovery of sensation took longer in the 25-microgram than in the 0-microgram and 10-microgram fentanyl groups, 101 +/- 21 vs 84 +/- 20 and 87 +/- 18 min (P < 0.05), although motor recovery and discharge times were the same. Postoperative analgesia was needed earlier in the 0-microgram than in the 25-microgram fentanyl group, median 54 (13-120) vs 87 (65-132) min (P < 0.05). Pruritus was the only side effect that occurred more often in the 10-microgram and 25-microgram groups than in the 0-microgram fentanyl group, 62% and 67% vs 14% (P < 0.0166). One patient required an epidural blood patch for postdural puncture headache. Based on these results, we concluded that 25 micrograms intrathecal fentanyl is required when 20 mg lidocaine is used for hypobaric spinal anesthesia (SA) to ensure reliable, durable anesthesia, reduce shoulder-tip pain, and minimize the need for intraoperative supplementation. This dose provides longer postoperative analgesia and does not increase side effects apart from pruritus. SA with small-dose hypobaric lidocaine-fentanyl was found to be a satisfactory technique for outpatient laparoscopy, although postdural puncture headache can occur in some patients.

Leukoencephalopathy associated with cobalamin deficiency.

Patients with cobalamin deficiency may experience cognitive impairment or neuropsychiatric symptoms. Although abnormalities of central myelin are the presumed cause of these manifestations, there is a paucity of reports of white matter lesions as shown on neuroimaging studies, and the effects of cobalamin replacement on these lesions are not known. We report a man with subacute cognitive impairment associated with cobalamin deficiency and remarkable confluent white matter abnormalities on MRI, confirmed by biopsy. With cobalamin replacement, both his cognitive deficits and imaging abnormalities partially resolved. This case indicates that leukoencephalopathy, in the absence of anemia or myelopathy, should be added to the spectrum of disorders associated with cobalamin deficiency. Early detection and treatment may be associated with a greater potential for recovery.

The effect of test chart design and human factors on visual performance with night vision goggles.

In an effort to increase flight safety, it is imperative to learn as much as possible about the man-goggle interrelationship. This study was undertaken to see if type of goggle or other covariates might affect visual acuity (VA). We tested the VA of 103 aircrew with both the AN/PVS-5 and Aviator's Night Vision Imaging System (ANVIS) goggles using a Snellen vision testing chart and the new Night Vision Goggle (NVG) Resolution (Grid Type) Chart. Average VA's using ANVIS (Snellen = 20/38, Grid = 20/45) were significantly better (p < 0.01) than VA's using AN/PVS-5 (Snellen = 20/54, Grid = 20/58). Snellen VA's were better on average than Grid VA's (p < 0.001). Neither age, gender, nor NVG experience affected average VA at the 0.05 level. Average VA was significantly better (p < 0.05) for non-spectacle wearers using ANVIS goggles and for non-smokers using AN/PVS-5 goggles. Visual acuity is better with ANVIS than with AN/PVS-5 goggles, and may be affected somewhat by wearing spectacles, and by smoking.

Residual tumor following radiotherapy for locally advanced carcinomas of the uterine cervix. Prognostic significance.

Over a five-year period from 1977 to 1982, 120 patients with locally advanced carcinomas of the uterine cervix were surgically staged by lymphadenectomy and laparotomy. Radiotherapy was then administered according to the pelvic extent of disease, and all patients underwent extrafascial total hysterectomy with adnexectomy at ten weeks after completing radiation therapy. The presence or absence of residual tumor in the hysterectomy specimen appeared to be an important prognostic factor in treatment success or failure. Patients with no residual tumor were found to have an excellent prognosis. Those with residual tumor clear of the resection margins were at risk for distant metastases. Only one survivor was noted in the group of patients in whom the margins of resection were involved with tumor, nearly all of these patients dying from local recurrences. Major operative morbidity in the series was minimal, and consisted of a single ureterovaginal fistula, which required urinary diversion.

Ovarian carcinoma: management of stress in patients and physicians.

A discussion of the management of ovarian cancer invariably involves the problems of death and dying faced by the patient, her family, and her physician. This paper attempts to deal with the general fears, anxieties, and problems of terminality, and also places attention on specific issues involved in living with the ongoing disease and its treatments. Focus is on the effects of the disease on the woman's self-image, on her family and relationships, on life outside the hospital, and on her relationship with her attending physician. Specific problems relating to the periods of (1) diagnosis, (2) operative management and treatment, and (3) terminality are discussed. Understanding the psychosocial realities of the patient provides the physician with added insights into methods to assist the patient in adaptation and coping with this ultimately fatal disease.

Outpatient breast biopsies on a gynecologic service.

One hundred forty-six breast biopsies in 143 patients were done on outpatient basis, without general anesthesia, on a gynecologic service between 1975 and 1980. This procedure has advantages over in-hospital biopsy in terms of cost, time, reduced immediate risk, and patient acceptance. Greater long-term risk, if carcinoma is found, has not been substantiated. Gynecologists need this procedure as an adjunct to the management of benign breast conditions and should be trained to do it.