Sleeve gastrectomy.

Much has been published over the last few years about sleeve gastrectomy. It is a bariatric operation that has evolved from both established restrictive and malabsorptive procedures. Originally used as a bridge to definitive surgery in high-risk patients, it has recently been forwarded as a stand-alone procedure. Technical details of laparoscopic sleeve gastrectomy (LSG) vary, but the premise is removal of the vast majority of the stomach, especially the fundus, leaving only a thin gastric tube between the esophagus and the duodenum. This results in weight loss from restrictive as well as neurohormal mechanisms. Review of the literature reveals an average expected excess weight loss (EWL) of 61%. Morbidity and mortality seem to be on par with laparoscopic adjustable gastric banding (LAGB), but with superior weight loss results and an improved long-term complication profile. Unlike popular mixed malabsorptive procedures like Roux en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD-DS), there is no gastrointestinal segment exclusion, maintaining continuity for endoscopic interventions and surveillance. Comorbidity resolution with LSG is variable, though compares favorably with other bariatric procedures. While the early results seem promising, long-term data is still needed to define the place of LSG within the bariatric surgery armamentarium.

Classical conditioning of the rabbit eyelid response with a mossy-fiber stimulation CS: I. Pontine nuclei and middle cerebellar peduncle stimulation.

The nictitating membrane/eyelid responses of 18 rabbits were classically conditioned using cerebellar mossy-fiber stimulation as a conditioned stimulus (CS) and air puff as an unconditioned stimulus (US). The dorsolateral, lateral, and medial pontine nuclei and the middle cerebellar peduncle were effective stimulation-CS sites for training. In one group of rabbits, robust conditioned eyelid responses were produced with paired trials and subsequently extinguished with CS-alone and explicitly unpaired presentation of the CS and US. In a second group of rabbits, no conditioned responses were evident for 4 days of unpaired CS and US presentations. Conditioned responses did develop, however, after paired training was begun. Lesions of the interpositus nucleus of the cerebellum completely abolished the conditioned responses of a third group of rabbits overtrained with the mossy-fiber CS and air-puff US. These results support previous studies which have demonstrated that the cerebellum is critically involved in acquisition and retention of simple learned responses. In addition, the present results support previous theories of cerebellar function which have proposed that mossy fibers supply critical "learning" input to the cerebellum for acquisition and retention of motor skills.

Use of the peripherally inserted central catheter for parenteral nutrition during pregnancy.

BACKGROUND: Parenteral nutrition is required during pregnancy to treat hyperemesis gravidarum and other conditions in which enteral intake is inadequate. We describe the peripherally inserted central catheter. The catheter is inserted into the antecubital vein using local analgesia, thus eliminating some of the risks associated with obtaining central venous access. CASE: Three pregnant patients required parenteral nutrition for refractory hyperemesis gravidarum. The peripherally inserted central catheter was successfully placed, and central venous administration of hyperosmolar solutions was accomplished without complication for periods of 28-137 days. Maternal weight gain and fetal growth were adequate. CONCLUSIONS: The peripherally inserted central catheter avoids some of the risks related to obtaining central venous access and permits long-term administration of parenteral nutrition into the central venous circulation.

Induction of labor versus expectant management in macrosomia: a randomized study.

OBJECTIVE: Macrosomia at term is associated with increased maternal and neonatal morbidity, including a higher rate of cesarean delivery and shoulder dystocia. Induction of labor has been suggested as a means to prevent further weight gain and improve outcome. The aim of this study was to determine whether or not induction of labor in these cases improves maternal and neonatal outcome. METHODS: Patients at term with an ultrasonic fetal weight estimation of 4000-4500 g were prospectively randomized into two groups: induction of labor (group D and expectant management (group II). Patients with diabetes, a previous cesarean delivery, or nonvertex presentation were excluded. Outcome variables included mode of delivery, arterial cord pH, presence of shoulder dystocia, brachial plexus injury, clavicular fracture, cephalohematoma, and intraventricular hemorrhage. RESULTS: Of 273 patients who were eligible for the study, 134 were randomized to group I and 139 to group II. Parity, gestational age, and fetal weight estimation were similar in the two groups. The neonates of group II patients were significantly heavier (4132.8 +/- 347.4 versus 4062.8 +/- 306.9 g; P = .024). The rate of cesarean delivery was 19.4% in group I and 21.6% in group II patients (not significant [NS]). Cord pH was similar in both groups. Shoulder dystocia was diagnosed in five group I and six group II patients (NS). None developed brachial plexus injury. There were two cases of mild, transient brachial plexus injury in group II patients without documented shoulder dystocia. Mild intraventricular hemorrhage was diagnosed in three of 44 group I and two of 31 group II neonates evaluated (NS). CONCLUSION: In this prospective, randomized study, induction of labor for suspected macrosomia at term did not decrease the rate of cesarean delivery or reduce neonatal morbidity. Ultrasonic estimation of fetal weight between 4000 and 4500 g should not be considered an indication for induction of labor.

Rapid transfer of training occurs when direct mossy fiber stimulation is used as a conditioned stimulus for classical eyelid conditioning.

Fifteen rabbits were classically conditioned using stimulation of the right pontine nuclei as a conditioned stimulus and a corneal airpuff as an unconditioned stimulus. After conditioning criterion was reached, the stimulation conditioned stimulus was transferred to the left pontine nuclei and the rate of conditioned response acquisition observed. Our results indicate that when electrodes were placed symmetrically in the right and left pontine nuclei, extremely rapid transfer of training occurred. Together with previous data, the present data supply further indirect evidence that the site of neural plasticity which underlies acquisition and retention of classically conditioned skeletal muscle responses is located efferent to the pontine nuclei, namely in the cerebellum.

Traumatic bone cyst resembling apical periodontitis.

Among the pseudocysts of the jaws, the traumatic bone cyst is known as an asymptomatic lesion often noted unintentionally during routine radiographic examinations. The lesion neither devitalizes the teeth within its borders, nor does it cause resorption of their roots. The well-demarcated traumatic bone cyst often projects into the intraradicular septa and hence has been described as having scalloped borders. The following presentation is of a traumatic bone cyst that resembled periodontal pathology in its appearance.

Primary gingival malignant melanoma. Report of 3 cases.

BACKGROUND: Malignant melanoma is rare in the oral cavity and accounts for less than 1% of all melanomas. Nevertheless, the disease can be fatal, and early diagnosis and treatment may improve prognosis dramatically. The purpose of this paper is to report 3 new cases of primary malignant melanoma of the oral cavity arising in the gingiva, and to review the literature regarding intraoral melanoma. METHODS: Three cases are presented. One case was in the right mandibular molar area; the second in the right maxillary canine-premolar area; and the third in the left mandibular canine-premolar region. All patients were treated surgically, with postoperative radiotherapy. RESULTS: The first patient lived for 2 years and the second for 3 years before distant metastases were diagnosed from which they subsequently died. The third patient was lost from follow-up after 18 months. CONCLUSION: Primary oral malignant melanoma is a deadly disease. Early suspicion of this disease will allow prompt treatment and increase the prognosis for these patients.

Conservative approach to multiple pregnancy with intrauterine fetal death of one or more fetuses.

One of the less common complications of multiple gestation is intrauterine demise of one or more fetuses. Despite the many case reports in the literature, there are no firm guidelines regarding the management of this problem. We herein report the favorable outcome of the conservative approach we chose for managing four patients; two with twins, one with triplets and one with quadruplets (first report in the literature). Strict follow-up based on frequent physical examinations, ultrasonographic assessment of fetal growth and well being, and coagulation profiles is mandatory. Individualization of delivery dates and mode is recommended.

Evaluation of lamellar body number density as the initial assessment in a fetal lung maturity test cascade.

The objective of this study was to assess the sensitivity and specificity of lamellar body number density in the prenatal prediction of the respiratory distress syndrome. Seventy consecutive amniotic fluid specimens obtained by amniocentesis within 72 hours of delivery were assessed for lamellar body number density, optical absorbance at 650 nm, lecithin/sphingomyelin ratio and phosphatidylglycerol. A maturity criterion of > or = 46,000/microL for lamellar body number density yielded values for diagnostic sensitivity of 100% (7/7), specificity of 89% (49/55), positive predictive value of 54% (7/13) and negative predictive value of 100% (49/49). These values were also determined for the other analytes, with results similar to those reported elsewhere. Lamellar body number density is an effective and inexpensive first test for the rapid identification of the fetus at high risk for the respiratory distress syndrome. A cascade approach, using lamellar body number density as the first test and optical absorbance at 650 nm as the second test, improves the predictive value as compared to any single test of fetal lung maturity.

Fetal surveillance. Should it begin at 40 weeks' gestation in a low-risk population?

We evaluated the possible benefits of antepartum surveillance during the 41st week of pregnancy in a low-risk population. Three hundred low-risk patients (study group) underwent a nonstress test (NST) at the beginning of the 41st week of pregnancy. Outcomes in study group patients who delivered during the 41st week were compared to those in 100 similar control patients who were not tested. One antepartum fetal demise occurred in each group: study group rate, 1/300 (0.3%); control group rate, 1/100 (1%), P > .05. During the 41st week, 158 of 300 (53%) study patients and 59 (59%) control patients delivered. Four of 158 (2.5%) study patients had labor induced for the indication of an abnormal antepartum test during the 41st week. Cesarean delivery for distress during the 41st week was performed on 1/157 (0.6%) study and 1/58 (1.7%) control patients (P > .05). No statistically significant improvement in outcome occurred in the study group even though 4 of 300 study group patients required induction of labor for abnormal antepartum testing during the 41st week of gestation. The current practice of not evaluating low-risk pregnancy with an NST until after the completion of 41 weeks is supported by the results of this study.

Acyclovir for disseminated herpes simplex virus in pregnancy. A case report.

Seventeen cases of disseminated herpes simplex virus (HSV) infection have occurred during pregnancy. Acyclovir therapy was associated with prolongation of the time from admission until spontaneous rupture of the membranes or delivery and an improved maternal outcome. This life-threatening condition has a typical presentation, which includes a nonspecific viral prodrome. During pregnancy, fever and anicteric hepatitis unresponsive to empiric antibiotics should prompt an evaluation for disseminated herpes simplex. Pharyngitis or skin lesions with a positive herpes simplex culture are common, specific signs associated with dissemination. The fever resolves within 48 hours in response to acyclovir therapy. One case of maternal disseminated HSV occurred at 22 weeks' gestation and resolved with acyclovir therapy; a healthy neonate was delivered vaginally at term.

Parenteral nutrition during pregnancy. Lack of association with idiopathic preterm labor or preeclampsia.

We reviewed published cases of lipid-containing parenteral nutrition during pregnancy to determine the incidence of idiopathic preterm labor and preeclampsia. Seventy-three reported cases of lipid-containing parenteral nutrition during pregnancy were identified. Idiopathic preterm labor occurred in 2 of 11 (18%) cases that delivered prior to term. Most patients who had preterm delivery while receiving parenteral nutrition had underlying medical conditions and/or coexistent obstetric problems that are associated with preterm delivery. Total parenteral nutrition during pregnancy was not associated with an increased risk of preterm delivery from idiopathic preterm labor. Preeclampsia was not reported in patients receiving lipid-containing parenteral nutrition. The lack of association of preeclampsia in patients receiving parenteral nutrition deserves further study.

Successful pregnancy outcome with combination therapy in women with the antiphospholipid antibody syndrome.

Four women with the antiphospholipid syndrome associated with lupus anticoagulant and a poor obstetric history were treated with a combination of glucocorticosteroids, anticoagulants and platelet inhibitor therapy. All patients had at least one previous miscarriage while receiving prednisone and low-dose aspirin. The treatment regimen included: aspirin, dipyridamole, prednisone, and warfarin or heparin. This treatment resulted in a successful pregnancy outcome in all cases, without preeclampsia or recurrence of thrombosis. One patient developed a vertebral compression fracture while receiving heparin and prednisone. Two pregnancies required cesarean delivery for fetal distress at 32 and 34 weeks. All four infant birth weights were appropriate for the gestational age. This regimen may be a therapeutic option for patients with the antiphospholipid antibody syndrome, especially if they have failed other commonly used treatments.

The contribution of pelvic ultrasonography to the diagnostic process in pediatric and adolescent gynecology.

We suggest that using the sonographic examination as an integral part of the work-up may save the physician and the patient from an unpleasant and uninformative examination, and avid EUA or unnecessary surgery. The type or sonographic examination should be determined by what is known, the equipment available, and the age and past history of the patient. In our institution the transabdominal approach is the choice for any nonsexually active female and the transvaginal approach is the procedure of choice for those females who are emotionally mature and sexually active. This review is addressed to the clinicians taking care of the pediatric and adolescent population. We wish to stress the importance of the sonographic evaluation as an immediate tool for the evaluation of suspected pelvic pathology, gender identity, and sexual-development disorders. We find it convenient and accurate, and feel that in children and young women with such pelvic complaints, it should be considered an important step in the diagnostic process.

[Falloposcopy--a new method for evaluation and treatment of infertility due to tubal factors].

Tubal factors cause infertility in about a third of cases. With current diagnostic techniques, such as laparoscopy and hysterosalpingography, only a fraction of the causes of tubal infertility can be diagnosed and in many cases misdiagnosis results. Newer methods, such as ampullosalpingoscopy enable examination of the fimbria and ampullar segment of the fallopian tube, but the examination of the proximal tube, in which 10-20% of occlusions occur, is still impossible. We describe a new diagnostic technique, falloposcopy. It involves the transuterine insertion of a fiber optic device into the fallopian tube through a hysteroscope. This technique enables direct visualization of all segments of the fallopian tube, as well as removal of intratubal debris or adhesions. Using falloposcopy, a new grading method for tubal disease has been developed. We describe the results of 129 falloposcopic procedures in 82 women. Following falloposcopy, women with mild to moderate disease, according to the new classification, have conceived without further therapy during a follow-up period of up to 3 years. Falloposcopy may aid in differentiating between patients suitable for tubal surgery and those who should be referred for in vitro fertilization.

Effect of resident physician education regarding selective chemoprophylaxis for the prevention of early onset group B streptococcal sepsis: an outcome study.

OBJECTIVE: The aim of this study was to evaluate the effect of a voluntary protocol for selective intrapartum chemoprophylaxis on the incidence of early onset group B streptococcal sepsis (GBS EOS). METHODS: Cases of GBS EOS were defined as a positive GBS culture from a normally sterile fluid obtained during the first 7 days of life. All cases of GBS EOS at an urban, university-affiliated community hospital were reviewed during 2 time periods. The 2-year period before instituting a resident education program to promote selective chemoprophylaxis (1988-89) was retrospectively reviewed; the 2-year period after the education program was introduced (1990-91) was prospectively recorded. The outcome measure was the incidence of GBS EOS. RESULTS: The rate of GBS EOS was 7/14,335 deliveries (0.05%) before and 9/13,999 (0.064%) after the introduction of the education program (observed difference between proportions 0.016%, 95% confidence interval [CI] for the difference between the proportions -0.071% to 0.04%, P = not significant [NS]). The rate of GBS EOS in preterm infants was 5/1,331 (0.376%) before and 3/1,297 (0.23%) afterward (observed difference between proportions 0.14%, 95% CI -0.28% to 0.56%, P = NS). The incidence of GBS EOS did not decrease during the latter period due to failure of antepartum cultures to predict intrapartum GBS colonization (2 cases); non-compliance with voluntary recommendations to administer chemoprophylaxis (2 cases); failure of chemoprophylaxis or therapy for intraamniotic infection to prevent neonatal infection (3 cases); and occurrence of GBS EOS in infants without risk factors (2 cases). CONCLUSIONS: An education program for resident physicians regarding chemoprophylaxis for GBS EOS did not significantly reduce the absolute incidence of disease. Alternative strategies are needed that redress the causes of failure inherent in the current guidelines. Some cases of GBS EOS are not preventable because the parturient does not have risk factors that indicate chemoprophylaxis.

Classical discrimination conditioning of the rabbit's eyelid response using pontine stimulation as a conditioned stimulus.

Classical discrimination conditioning of the nictitating membrane/eyelid response was performed on seven rabbits using stimulation of the pontine nuclei or middle cerebellar peduncle as the conditioned stimulus (CS) and an air puff as the unconditioned stimulus (US). The rabbits learned to discriminate between a CS paired with a US and delivered to one pontine nucleus (the CS+) and a CS presented alone and delivered to the contralateral pontine nucleus (the CS-). Subsequent reversal of the discrimination was also achieved when the CS+ and CS- stimulation sites were interchanged. The results are interpreted as support for the idea that essential plasticity for classical eyelid conditioning occurs efferent to the pontine nuclei, possibly in regions of the cerebellum.

Repeated external cephalic version at term.

External version was performed three times in a patient at term because of spontaneous reversion to breech presentation. She was then delivered vaginally. Spontaneous reversion to breech presentation can be managed with additional external cephalic version procedures.

Toxic shock syndrome after loop electrosurgical excision procedure.

Toxic shock syndrome can occur after any surgical procedure. We report the first case of toxic shock syndrome that has occurred after a loop electrosurgical excision procedure. The patient recovered with supportive care and antibiotics.