Dilatation and curettage increases the risk of subsequent preterm birth: a systematic review and meta-analysis.

STUDY QUESTION: Could dilatation and curettage (D&C), used in the treatment of miscarriage and termination of pregnancy, increase the risk of subsequent preterm birth? SUMMARY ANSWER: A history of curettage in women is associated with an increased risk of preterm birth in a subsequent pregnancy compared with women without such history. WHAT IS KNOWN ALREADY: D&C is one of the most frequently performed procedures in obstetrics and gynaecology. Apart from the acknowledged but relatively rare adverse effects, such as cervical tears, bleeding, infection, perforation of the uterus, bowel or bladder, or Asherman syndrome, D&C has been suggested to also lead to an increased risk of preterm birth in the subsequent pregnancy. STUDY DESIGN, SIZE, DURATION: In the absence of randomized data, we conducted a systematic review and meta-analysis of cohort and case-control studies. PARTICIPANTS/MATERIALS, SETTING, METHODS: We searched OVID MEDLINE and OVID EMBASE form inception until 21 May 2014. We selected cohort and case-control studies comparing subsequent preterm birth in women who had a D&C for first trimester miscarriage or termination of pregnancy and a control group of women without a history of D&C. MAIN RESULTS AND THE ROLE OF CHANCE: We included 21 studies reporting on 1 853 017 women. In women with a history of D&C compared with those with no such history, the odds ratio (OR) for preterm birth <37 weeks was 1.29 (95% CI 1.17; 1.42), while for very preterm birth the ORs were 1.69 (95% CI 1.20; 2.38) for <32 weeks and 1.68 (95% CI 1.47; 1.92) for <28 weeks. The risk remained increased when the control group was limited to women with a medically managed miscarriage or induced abortion (OR 1.19, 95% CI 1.10; 1.28). For women with a history of multiple D&Cs compared with those with no D&C, the OR for preterm birth (<37 weeks) was 1.74 (95% CI 1.10; 2.76). For spontaneous preterm birth, the OR was 1.44 (95% CI 1.22; 1.69) for a history of D&C compared with no such history. LIMITATIONS, REASONS FOR CAUTION: There were no randomized controlled trials comparing women with and without a history of D&C and subsequent preterm birth. As a consequence, confounding may be present since the included studies were either cohort or case-control studies, not all of which corrected the results for possible confounding factors. WIDER IMPLICATIONS OF THE FINDINGS: This meta-analysis shows that D&C is associated with an increased risk of subsequent preterm birth. The increased risk in association with multiple D&Cs indicates a causal relationship. Despite the fact that confounding cannot be excluded, these data warrant caution in the use of D&C for miscarriage and termination of pregnancy, the more so since less invasive options are available. STUDY FUNDING/COMPETING INTERESTS: This study was funded by ZonMw, a Dutch organization for Health Research and Development, project number 80-82310-97-12066.

MisoREST: surgical versus expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment for miscarriage: a randomized controlled trial.

STUDY QUESTION: Is curettage more effective than expectant management in case of an incomplete evacuation after misoprostol treatment for first trimester miscarriage? SUMMARY ANSWER: Curettage leads to a higher chance of complete evacuation but expectant management is successful in at least 76% of women with an incomplete evacuation of the uterus after misoprostol treatment for first trimester miscarriage. WHAT IS KNOWN ALREADY: In 5-50% of the women treated with misoprostol, there is a suspicion of incomplete evacuation of the uterus on sonography. Although these women generally have minor symptoms, such a finding often leads to additional curettage. STUDY DESIGN, SIZE, DURATION: From June 2012 until July 2014, we conducted a nationwide multicenter randomized controlled trial (RCT). Women who had had primary misoprostol treatment for miscarriage with sonographic evidence of incomplete evacuation of the uterus were randomly allocated to either curettage or expectant management (1:1), using a web-based application. PARTICIPANTS/MATERIALS, SETTING, METHODS: We included 59 women in 27 hospitals; 30 were allocated to curettage and 29 were allocated to expectant management. A successful outcome was defined as sonographic finding of an empty uterus 6 weeks after randomization. MAIN RESULTS AND THE ROLE OF CHANCE: Baseline characteristics of both groups were comparable. Empty uterus on sonography or uneventful clinical follow-up was seen in 29/30 women (97%) allocated to curettage compared with 22/29 women (76%) allocated to expectant management (RR 1.3, 95% CI 1.03-1.6) with complication rates of 10% versus 10%, respectively (RR 0.97, 95% CI 0.21-4.4). In the group allocated to curettage, no woman required re-curettage, while two women (6.7%) underwent hysteroscopy (for other or unknown reasons). In the women allocated to expectant management, curettage was performed in four women (13.8%) and three women (10.3%) underwent hysteroscopy. LIMITATIONS, REASONS FOR CAUTION: Due to a strong patient preference, mainly for expectant management, the targeted sample size could not be included and the trial was stopped prematurely. WIDER IMPLICATIONS OF THE FINDINGS: In women suspected of incomplete evacuation of the uterus after misoprostol, curettage is more effective than expectant management. However, expectant management is equally safe and prevents curettage for most of the women. This finding could further restrain the use of curettage in the treatment of first trimester miscarriage. STUDY FUNDING/COMPETING INTERESTS: This study was funded by ZonMw, a Dutch organization for Health Research and Development, project number 80-82310-97-12066. There were no conflicts of interests. TRIAL REGISTRATION NUMBER: Dutch Trial Register NTR3310, http://www.trialregister.nl TRIAL REGISTRATION DATE: 27 February 2012. DATE OF FIRST PATIENT'S ENROLMENT: 12 June 2012.

Aetiology, risk factors and preventive strategies for niche development: A review.

The increase in caesarean sections (CS) has resulted in an increase in women with a uterine niche. The exact aetiology of niche development has yet to be elucidated but is likely multifactorial. This study aimed to give a systematic overview of the available literature on histopathological features, risk factors and results of preventive strategies on niche development to gain more insight into the underlying mechanisms. Based on current published data histopathological findings associated with niche development were necrosis, fibrosis, inflammation, adenomyosis and insufficient approximation. Patient-related risk factors included multiple CS, BMI and smoking. Labour-related factors were CS before onset of labour, extended cervical dilatation, premature rupture of membranes and presenting part of the fetus at CS below the pelvic inlet. Preventive strategies should focus on the optimal level of incision, training of surgeons and full-thickness closure of the myometrium (single or double-layer) using non-locking sutures. Conflicting data exist concerning the effect of endometrial inclusion. Future studies without heterogeneity in population, using standardized performance of the CS after proper training and using standardized niche evaluation with a relevant core outcome set are required to allow meta-analyses and to develop evidence-based preventive strategies. These studies are needed to reduce the prevalence of niches and prevent complications in subsequent pregnancies such as caesarean scar pregnancies.

Are routine repeat chest x-rays before leaving the trauma room useful?

BACKGROUND: Several guidelines advocate multiple chest x-rays during primary resuscitation of trauma patients. Some local hospital protocols include a repeat x-ray before leaving the trauma resuscitation room (TR). The purpose of this study was to determine the value of routine repeat x-rays. METHODS: One-year data of all radiological imaging in the TR were prospectively collected for all patients presenting to the TR of the hospital. The x-rays were counted and assessed and the findings were classified as either 'new injury detected', 'presence of intervention devices' or 'deterioration of previously detected injury'. RESULTS: A total of 674 patients were included. More than 75% had two x-rays. Eight (2.1%) new injuries without clinical relevance were found on the repeat x-ray after an initial normal x-ray. 61 patients (9%) had a repeat x-ray to verify the effect of an intervention or position of devices. In 28 patients (22%) with two abnormal x-rays, newly diagnosed injuries (n=9) or deterioration of known injuries (n=19) were found. In 411 patients (81%) the results of the repeat x-ray had no clinical consequences. CONCLUSION: This study indicates that routine repeat chest x-rays can be omitted in trauma patients whose initial chest x-ray is normal.

Fertility and obstetric outcomes after curettage versus expectant management in randomised and non-randomised women with an incomplete evacuation of the uterus after misoprostol treatment for miscarriage.

OBJECTIVE: To assess fertility and obstetric outcomes in women treated with curettage or undergoing expectant management for an incomplete miscarriage after misoprostol treatment. STUDY DESIGN: Between June 2012 and July 2014, we conducted a multicentre randomised clinical trial (RCT) with a parallel cohort study for non-randomised women, treated according to their preference. In the RCT 30 women were allocated curettage and 29 expectant management. In the cohort 197 women participated; 65 underwent curettage and 132 women underwent expectant management. Primary outcome was curation, defined as either an empty uterus on sonography at six weeks or an uneventful clinical follow-up. We used questionnaires to assess fertility and obstetric outcome of the first new pregnancy subsequent to study enrolment. RESULTS: Curation was seen in 91/95 women treated with curettage (95.8%) versus 134/161 women managed expectantly (83.2%) (p=0.003). The response rate was 211/255 (82%). In 198 women pursuing a new pregnancy, conception rates were 92% (67/73) in the curettage group versus 96% (120/125) in the expectant management group (OR 0.96, 95% CI 0.89;1.03, p=0.34), with ongoing pregnancy rates of 87% (58/67) versus 78% (94/120), respectively (OR 1.12, 95% CI 0.99;1.28, p=0.226). Preterm birth rates were 1/46 in the curettage group versus 8/81 in the expectant management group (OR 0.22, 95% CI 0.03;1.71 P=0.15). Caesarean section rates were 23% and 24% for women in the curettage group and expectant management group respectively. CONCLUSION: In women with an incomplete evacuation of the uterus after misoprostol treatment, curettage and expectant management does not lead to different fertility and pregnancy outcomes, as compared to expectant management.

Major role for arterial disease in morbidity and mortality after kidney transplantation in diabetic recipients.

OBJECTIVE: To identify clinical characteristics of diabetic end-stage renal disease patients that place individual transplant candidates at high risk for arterial morbidity and mortality after transplantation. RESEARCH DESIGN AND METHODS: We studied the course of 101 sequential renal allograft recipients with insulin-dependent diabetes mellitus, transplanted between 10 November 1980 and 1 April 1986. Arterial disorders were tabulated from medical records and interviews with individual patients, their families, and their private physicians. Documentation of discrete arterial events included recorded physical examinations, radiographic studies, laboratory data, electrocardiograms, peripheral vascular flow studies, and operative reports. The prevalence of preoperative arterial disease was compared with the occurrence of new arterial events after kidney transplantation. RESULTS: Within a mean follow-up period of 47 mo, a 30% absolute mortality rate was observed. Of these deaths, 57% resulted from arterial disorders. Clinical manifestations of arterial disease were recognized in 41% of recipients before transplantation, and 78% of these patients suffered new vascular events after transplantation. Of the entire sample, 57% developed at least one new complication of arterial disease after transplantation, whereas only 34% had no vascular diagnosis before or after transplantation. Cerebral, coronary, and peripheral arterial complications after transplantation occurred in 14, 28, and 36% of the patients, respectively. The corresponding incidences of stroke, myocardial infarction, and amputation were 12, 14, and 25%. Pretransplant coronary artery disease predisposed to new coronary events after transplantation, but only peripheral arterial complications occurred more often after transplantation compared with the preoperative period. The probability of arterial complications or death correlated with patient age at first transplant and duration of diabetes but not with sex or smoking history. CONCLUSIONS: Intrinsic arterial disease in diabetic renal allograft recipients contributes heavily to the long-term morbidity and mortality after transplantation and poses the major threat to survival. Diabetic transplant candidates greater than 35 yr of age or with clinical evidence of arterial disease should undergo an extensive vascular assessment, including stress thallium myocardial imaging and/or coronary arteriography. Such recipients should receive careful preoperative counseling about their excess risk for subsequent arterial disorders.

Efficacy and safety of low molecular weight heparin in renal transplantation.

BACKGROUND: Deep venous thrombosis (DVT) is a common problem with potentially devastating results in patients undergoing major surgical procedures. Certain renal transplant recipients are particularly at risk for allograft loss as a consequence of renal vein and artery thrombosis. Over the past few years, low molecular weight heparin has been well established as an accepted modality of treatment and prophylaxis of DVT. The efficacy and safety of low molecular weight heparin in the prophylaxis of DVT following renal transplantation in adults has not previously been reported. METHODS: Dalteparin was administered to 120 adult renal transplant recipients postoperatively at the Oregon Health Sciences University. RESULTS: No patient developed allograft arterial or venous thrombosis. One patient developed subclavian vein thrombosis. No bleeding complications were encountered, and side effects were very minimal. CONCLUSION: Prophylaxis with dalteparin is an effective and safe modality for the prevention of thrombosis in adult patients undergoing renal transplantation.

Prostatic occurrence of transitional cell carcinoma after intravesical chemotherapy.

Thirteen patients with Stage Tis, Ta, or T1 transitional cell carcinoma (TCC) of the bladder treated by transurethral resections and intravesical chemotherapy developed TCC of the prostate. Among the 13 cases, cytology specimens were obtained from 10 at the time prostatic disease was diagnosed; 9 demonstrated TCC. One was treated successfully by transurethral resection of a Ta lesion involving the prostatic urethra only. One of 2 patients declining radical surgery is alive with residual disease at twenty-four months, and the other died of progressive disease at nineteen months. Of the 10 patients who underwent radical cystoprostatectomy, 7 are alive with no evidence of disease eight to forty-two months postoperatively, with 2 of these 7 having received 4 courses of systemic methotrexate, vincristine, Adriamycin, and cisplatinum (MVAC) for metastatic disease. Two of the 10 died of metastatic disease six and thirteen months postoperatively, and one frail patient died of surgical complications. When treating patients with intravesical chemotherapy for superficial TCC, biopsy of the prostate should be done during follow-up examinations, especially in the presence of cytologic or palpable prostatic abnormalities.

MAG3 renal transplant tomography SPECT with a non-SPECT agent.

The authors encountered a renal transplant patient in whom tubular stasis permitted sufficient time to perform SPECT using Tc-99m MAG3. SPECT revealed a defect that was not apparent on the planar study. Renal biopsy showed acute vascular rejection. On a subsequent Tc-99m MAG3 SPECT study the defect had resolved.

Renal transplant nuclear tomography using Tc-99m MAG3.

In this study, the authors performed SPECT imaging on 12 renal transplant patients immediately after a routine planar study demonstrated tubular stasis. The stasis allowed the authors to obtain good quality tomograms on all of them. In five patients, the findings on the planar and SPECT studies were identical. In five patients, there was decreased upper pole activity on planar images and SPECT imaging differentiated between attenuation (4 patients) and cortical thinning (1 patient). In the remaining two patients, the SPECT images showed unanticipated information. It is not yet clear if this new information is of clinical value. It was concluded that diagnostic quality nuclear tomograms in renal transplant patients with tubular stasis can be easily and consistently obtained.

Multiple shear-banding transitions in a supramolecular polymer solution.

We report on the nonlinear rheology of a reversible supramolecular polymer based on hydrogen bonding. The coupling between the flow-induced chain alignment and breakage and recombination of bonds between monomers leads to a very unusual flow behavior. Measured velocity profiles indicate three different shear-banding regimes upon increasing shear rate, each with different characteristics. While the first of these regimes has features of a mechanical instability, the second shear-banding regime is related to a shear-induced phase separation and the appearance of birefringent textures. The shear-induced phase itself becomes unstable at very high shear rates, giving rise to a third banding regime.

De novo carcinoma of the lower urinary tract in renal allograft recipients.

Immunocompetence has been postulated as an important defense against the progression of urothelial carcinoma. Three cases of de novo lower urinary tract carcinoma in renal transplant recipients demonstrated the potential for unusually rapid urothelial extension and invasion in chronically immunosuppressed patients. Two patients had a history of perineal condyloma acuminata; tumors from 1 of these harbored the genetic sequences of human papillomavirus type 6. One patient had multiple manifestations of cyclophosphamide-related urothelial injury, including bladder carcinoma. Treatment of 2 patients culminated in a radical operation during which the remaining native urinary system was resected completely, with sacrifice of the allograft kidney in 1 and diversion into an ileal conduit in 1. The remaining patient underwent urethrectomy and partial cystectomy with a sigmoid conduit.

Patch and flap techniques to repair right renal vein defects caused by cadaver liver retrieval for transplantation.

We describe 2 techniques that allow right renal vein extension and prevent renal vein stenosis if the cephalic portion of the renal vein has been amputated when the liver is separated from the kidneys during multiple organ retrieval. These techniques were successfully used in 8 cadaver kidney transplant recipients.

Scrotal arteriovenous malformation: case report and literature review.

We report a rare case of scrotal arteriovenous malformation in an adolescent. Arteriovenous malformation of the scrotum is distinguished radiographically and histologically by numerous arterioles and thick walled veins with no intervening capillary bed. The cardinal sign is a bruit. Complete excision is recommended as definitive treatment. Preoperative angio-embolization may be helpful but it should not be relied upon for clinical resolution.

Renal adenocarcinoma with solitary metastasis to the contralateral adrenal gland: report of 2 cases and review of the literature.

We report 2 rare cases of renal adenocarcinoma with solitary metastasis to the contralateral adrenal gland, 1 recognized synchronously with the primary neoplasm and 1 found 15 years after nephrectomy. The latter case represents the longest reported interval between nephrectomy and treatment of a solitary contralateral adrenal metastasis of renal adenocarcinoma. Distinction of these metastatic tumors from primary adrenocortical carcinoma was facilitated by immunohistochemical markers. Twelve other reported cases of renal adenocarcinoma with solitary contralateral adrenal metastasis support aggressive surgical management of this lesion.

Extravesical ureteroneocystostomy for duplicated allograft ureters.

We report a modification of unstented, parallel incision, extravesical ureteroneocystostomy for duplicated ureters. The technique is simple and effective, and requires no routine stenting.

Postoperative cystography is unnecessary following renal transplantation with parallel incision extravesical ureteroneocystostomy.

PURPOSE: To determine the need for postoperative cystography following extravesical ureteroneocystostomy for renal transplantation. MATERIALS AND METHODS: The clinical courses of 200 consecutive kidney transplant recipients who underwent urinary tract reconstruction by parallel incision extravesical ureteroneocystostomy were reviewed. RESULTS: Five of the 200 recipients did not have the study because of early mortality (1) or medical problems (4). Grade I vesicoureteral reflux was present in 5 (3%) of 182 unstented allograft ureters and 5 of 13 stented allograft ureters. Two patients (1%) underwent repeat ureteroneocystostomy, one for obstruction and one for extravasation. The cystograms were normal in both patients. CONCLUSIONS: Routine retrograde cystography is unnecessary following urinary tract reconstruction by parallel incision extravesical ureteroneocystostomy.

Indication, surgical technique and outcome of orthotopic renal transplantation.

PURPOSE: We review the indication, surgical technique and outcome of orthotopic renal transplantation. MATERIALS AND METHODS: The medical records of 1,000 patients who underwent renal transplantation at our institution between August 24, 1993 and August 1, 2000, as well as orthotopic renal transplantation were reviewed. RESULTS: Orthotopic renal transplantation was performed in 4 males and 1 female with severe iliac atherosclerosis or retained bilateral iliac fossa kidney transplant. Mean patient age was 56 years. There were 2 patients who received kidneys from living related donors, and 3 underwent cadaveric renal transplantation. Left orthotopic renal transplantation was successful in 4 cases, and 1 was converted to iliac fossa renal transplant because of a pulseless splenic artery and renal artery thrombosis after native renal endarterectomy. Orthotopic renal revascularization was done with splenic artery in 2, native renal artery in 2 and left renal vein in all 4 patients. Urinary tract reconstruction was performed with stented (2) or nonstented (2) ureteroureterostomy. Antibody induction, purine antagonists, calcineurin inhibitors and glucocorticoids were used for immunosuppression. Mean preoperative and 1-month postoperative serum creatinine was 7.9 and 1.3 mg./dl., respectively. Patient and graft survival was 100% during followup, which ranged from 6 months to 5 years. CONCLUSIONS: Despite the technical challenges, orthotopic renal transplantation in patients with unsuitable pelvic vessels can result in excellent patient and graft survival.

Nucleotide sequence and transcript map of the Agrobacterium tumefaciens Ti plasmid-encoded octopine synthase gene.

We have determined the complete nucleotide sequence of the gene for the crown gall enzyme, octopine synthase. The sequence was derived from cloned fragments of the Agrobacterium tumefaciens Ti plasmid Ach5. It displayed a continuous open reading frame encoding a polypeptide chain of 358 amino acids. The nucleotide positions corresponding to the 5' end and poly(A) addition site of the mature octopine synthase mRNA from a tobacco tumor cell line were determined by S1 nuclease mapping. Two sequences closely resembling transcriptional control regions found in eukaryotic genes transcribed by RNA polymerase II were identified in the flanking genomic DNA: a sequence 5'-TATTTAAA-3' was located 32 base pairs upstream from the initiation site of transcription, and a hexanucleotide 5'-AATAAT-3' occurred 17 base pairs in front of the poly(A) addition site. No Shine-Dalgarno sequence was present in the untranslated 5' leader sequence. The observations indicate that this DNA sequence, although naturally carried by a bacterial plasmid, is programmed as a functional plant gene.