Perimenstrual psychiatric hospitalization: case report and literature review.

Despite the fact that menstrual psychosis has been described since the eighteenth century, there are only about 80 cases reported in the literature. The knowledge and awareness about the disorder remain poor, leading to inaccurate diagnoses and suboptimal treatment. This is the case of a 25-year-old woman with recurrent hospitalizations for mental status changes including psychotic phenomena and catatonia that appeared to follow a cyclical pattern that correlated with her menstrual periods, with complete symptom resolution and return to her usual level of functioning between episodes despite continued treatment with antipsychotic medications. This pattern remitted only after hormonal therapy was initiated. Through this case report, the authors review the literature on the menstrual psychoses, exemplified by this case, and discuss treatment options and prognosis. Menstrual psychosis is an underrecognized condition where psychotic symptoms recur cyclically with menses. Given the poor response that this entity shows to antipsychotic treatment, hormonal therapies have a prominent role.

Contained tissue extraction using power morcellation: prospective evaluation of leakage parameters.

BACKGROUND: Safe tissue removal is a challenge for minimally invasive procedures such as myomectomy, supracervical hysterectomy, or total hysterectomy of a large uterine specimen. There is concern regarding disruption or dissemination of tissue during this process, which may be of particular significance in cases of undetected malignancy. Contained tissue extraction techniques have been developed in an effort to mitigate morcellation-related risks. OBJECTIVE: The objective of the study was to quantify perioperative outcomes of contained tissue extraction using power morcellation, specifically evaluating parameters of tissue or fluid leakage from within the containment system. STUDY DESIGN: This was a study including a multicenter prospective cohort of adult women who underwent minimally invasive hysterectomy or myomectomy using a contained power morcellation technique. Blue dye was applied to the tissue specimen prior to removal to help identify cases of fluid or tissue leakage from within the containment system. RESULTS: A total of 76 patients successfully underwent the contained power morcellation protocol. Mean time for the contained morcellation procedure was 30.2 minutes (±22.4). The mean hysterectomy specimen weight was 480.1 g (±359.1), and mean myomectomy specimen weight was 239.1 g (±229.7). The vast majority of patients (73.7%) were discharged home the same day of surgery. Final pathological diagnosis was benign in all cases. Spillage of dye or tissue was noted in 7 cases (9.2%), although containment bags were intact in each of these instances. CONCLUSION: Findings are consistent with prior work demonstrating the feasibility of contained tissue extraction; however, further refinement of this technique is warranted.

Risk of leakage and tissue dissemination with various contained tissue extraction (CTE) techniques: an in vitro pilot study.

STUDY OBJECTIVE: To evaluate risk of leakage and tissue dissemination associated with various contained tissue extraction (CTE) techniques. DESIGN: In vitro study (Canadian Task Force classification: II-1). SETTING: Academic hospital simulation laboratory. INTERVENTION: Beef tongue specimens weighing 400 to 500 g were stained using 5 mL indigo carmine dye and morcellated under laparoscopic guidance within a plastic box trainer. CTE was performed via 3 different techniques: a stitch-sealed rip-stop nylon bag and multi-port approach; a one-piece clear plastic 50 × 50-cm isolation bag and multi-port approach; or a 1-piece clear plastic 50 × 50-cm isolation bag and single-site approach. Four trials of each CTE method were performed and compared with an open morcellation control. All bags were insufflated to within 10 to 25 mmHg pressure with a standard CO2 insufflator. Visual evidence of spilled tissue or dye was recorded, and fluid washings of the box trainer were sent for cytologic analysis. MEASUREMENTS AND MAIN RESULTS: Blue dye spill was noted in only 1 of 12 CTE trials. Spillage was visualized from a seam in 1 of the 4 stitch-sealed rip-stop nylon bags before morcellation of the specimen. The only trial in which gross tissue chips were visualized in the box trainer after morcellation was the open morcellation control. However, cytologic examination revealed muscle cells in the open morcellation washings and in the washings from the trial with dye spill. Muscle cells were not observed at cytologly in any of the other samples. CONCLUSION: CTE did not result in any leakage or tissue dissemination with use of the single-site or multi-port approach when using a 1-piece clear plastic 50 × 50-cm isolation bag. Further studies are needed to corroborate these findings in an in vivo context and to evaluate use of alternate bag options for specimen containment.

Radiofrequency Ablation of Leiomyomas.

Radiofrequency ablation (RFA) of leiomyomas represents a significant advancement in the treatment of this common uterine condition. In the appropriately selected patient, both laparoscopic and transcervical options provide effective treatment for bleeding and bulk symptoms in a uterine-sparing manner. Compared with other minimally invasive leiomyoma treatment options, RFA procedures have comparable or favorable safety profiles, recovery timelines, and reintervention rates. Data on future fertility and pregnancy are limited, although early reports are promising.

Coffee, hunger, and peptide YY.

OBJECTIVE: There is evidence from several empirical studies suggesting that coffee may help people control body weight. Our objective was to assess the effects of caffeine, caffeinated coffee, and decaffeinated coffee, both alone and in combination with 75 g of glucose, on perceived hunger and satiety and related peptides. METHODS: We conducted a placebo-controlled single-blinded randomized 4-way crossover trial. Eleven healthy male volunteers (mean age, 23.5 ± 5.7 years; mean BMI, 23.6 ± 4.2 kg/m(2)) ingested 1 of 3 test beverages (caffeine in water, caffeinated coffee, or decaffeinated coffee) or placebo (water), and 60 minutes later they ingested the glucose. Eight times during each laboratory visit, hunger and satiety were assessed by visual analog scales, and blood samples were drawn to measure 3 endogenous peptides associated with hunger and satiety: ghrelin, peptide YY (PYY), and leptin. RESULTS: Compared to placebo, decaffeinated coffee yielded significantly lower hunger during the whole 180-minute study period and higher plasma PYY for the first 90 minutes (p < 0.05). Caffeine in water had no effects on hunger or PYY. Caffeinated coffee showed a pattern between that of decaffeinated coffee and caffeine in water. These findings suggest that one or more noncaffeine ingredients in coffee may have the potential to decrease body weight. Glucose ingestion did not change the effects of the beverages. CONCLUSIONS: Our randomized human trial showed that decaffeinated coffee can acutely decrease hunger and increase the satiety hormone PYY.

Point-of-care assessment of combined umbilical arterial and venous lactate: A potential screening test for neonatal acidosis.

OBJECTIVE: To examine the relationship between point-of-care (POC) measurement of combined umbilical arterial and venous (CUAV) lactate and umbilical artery (UA) lactate to determine whether POC assessment of this sample could be an alternative screening modality for neonatal acidosis and aid prediction of neonatal morbidity. METHODS: In this cross-sectional pilot study, UA and CUAV cord blood samples were collected from live, singleton neonates delivered between June and August 2019, at a tertiary care center. UA samples were analyzed for pH and lactate using a blood gas analyzer. CUAV lactate was also assessed on a blood gas analyzer and at the POC. Linear regression was used to determine the correlation between these samples. RESULTS: A total of 152 neonates were included. There was a statistically significant correlation between CUAV lactate concentrations and UA lactate concentrations (R2  = 0.744). Additionally, CUAV lactate concentration measured at the POC was significantly correlated with that measured on a traditional blood gas analyzer (R2  = 0.928). CONCLUSION: POC testing of CUAV lactate is reliable and closely correlated with UA lactate concentrations, making POC testing of CUAV lactate a potential screening test for neonatal acidosis. More data are needed to establish standardization of this test relative to its predictive value in clinical neonatal outcomes.

Is an episiotomy necessary with a shoulder dystocia?

OBJECTIVE: The objective of the study was to determine whether a decrease in the use of episiotomy was associated with a change in the frequency of brachial plexus injury. STUDY DESIGN: All births at Brigham and Women's Hospital from Sept. 1, 1998, through Aug. 31, 2009, were reviewed. The total number of births, mode of delivery, shoulder dystocias, episiotomies with and without shoulder dystocias, and brachial plexus injuries were recorded. A nonparametric test of trend was performed. RESULTS: There were a total of 94,842 births, 953 shoulder dystocias, and 102 brachial plexus injuries. The rate of episiotomy with shoulder dystocia dropped from 40% in 1999 to 4% in 2009 (P = .005) with no change in the rate of brachial plexus injuries per 1000 vaginal births. CONCLUSION: Despite historical recommendations for an episiotomy to prevent brachial plexus injury when a shoulder dystocia is encountered, the trend we observed does not suggest benefit from this practice.

Eggs, dietary cholesterol, choline, betaine, and diabetes risk in the Women's Health Initiative: a prospective analysis.

BACKGROUND: Epidemiological studies have been inconsistent regarding the relations between diabetes risk and the consumption of eggs and nutrients in eggs, such as choline, betaine, and cholesterol. There have been few studies among elderly women. OBJECTIVES: The objective of this study was to examine associations between consumption of eggs, cholesterol, choline, and betaine and the risk of diabetes among elderly US women. METHODS: Multivariable Cox regression was used with data from the prospective Women's Health Initiative. Population attributable risks were calculated. Consumption of eggs alone (not mixed in foods) and nutrients were assessed with an FFQ. Diabetes incidence was defined as the first incidence of self-reported diabetes treated with oral diabetes medication or insulin injections. RESULTS: There were 46,263 women at follow-up baseline. During 13.3 y and 592,984 person-years of follow-up, there were 5480 incident diabetes cases. Higher egg, cholesterol, and choline consumption were each significantly associated with increases in diabetes risk. The associations for eggs and choline were not significant after adjustment for cholesterol consumption. The association for eggs was attenuated after adjustment for non-egg cholesterol consumption, with 1 significant HR in the top consumption quintile (≥3 eggs/wk) of 1.15 (95% CI: 1.05, 1.27; P for linear trend = 0.0001). The population attributable risks for obesity, overweight, consumption of ≥3 eggs/wk, inadequate exercise, and poor diet were 25.0 (95% CI: 22.3, 27.6), 12.8 (95% CI: 11.1, 14.5), 4.2 (95% CI: 2.3, 6.1), 3.5 (95% CI: 1.2, 5.8), and 3.1 (95% CI: 0.5, 5.7), respectively. CONCLUSIONS: As egg consumption increased to ≥3 eggs/wk, there was a steady increase in diabetes risk that may have been due to the cholesterol in the eggs. The population attributable risk for ≥3 eggs/wk was far lower than that for being obese or overweight.

Chocolate Candy and Incident Invasive Cancer Risk in the Women's Health Initiative: An Observational Prospective Analysis.

BACKGROUND: Laboratory and animal studies suggest an inverse association between chocolate consumption and the risk of cancer. Epidemiological studies have yielded inconsistent evidence. OBJECTIVE: To assess the association of chocolate candy consumption with incident, invasive total, breast, colorectal, and lung cancers in a large cohort of postmenopausal American women. DESIGN: Prospective cohort study with a mean 14.8-year follow-up. Chocolate candy intake was assessed by food frequency questionnaire. Invasive cancer events were assessed by physician adjudication. PARTICIPANTS/SETTING: The Women's Health Initiative Study enrolled 161,808 postmenopausal women at 40 clinical centers nationwide between 1993 and 1998. Of these women, 114,281 with plausible food frequency or biometric data and no missing data on chocolate candy exposure were selected for analysis. MAIN OUTCOME MEASURES: Cancer risk in quartiles of chocolate candy consumption with the first quartile as referent. STATISTICAL ANALYSES: Multivariable Cox regression was used to calculate hazard ratios and 95% confidence intervals. RESULTS: There were 16,164 documented incident invasive cancers, representing an incidence rate of 17.0 per 100 participants and 12.3 per 1000 person years during follow-up among participants without any preexisting cancers or missing outcome data. There were no statistically significant associations for total invasive cancer (P-linear = .47, P-curvature = .14), or invasive breast cancer (P-linear = .77, P-curvature = .26). For colorectal cancer P-linear was .02, P-curvature was .03, and compared with women eating a 1 oz (28.4 g) chocolate candy serving <1 time per month, the hazard ratio for ≥1.5 times/wk was 1.18 (95% confidence interval: 1.04-1.35). This result may be attributable to the excess adiposity associated with frequent chocolate candy consumption. CONCLUSIONS: In the Women's Health Initiative, there was no significant association between chocolate candy consumption and invasive total or breast cancer. There was a modest 18% higher risk of invasive colorectal cancer for women who ate chocolate candy at least 1.5 times/wk. These results require confirmation.

Bidirectional barbed suture: an evaluation of safety and clinical outcomes.

OBJECTIVE: To evaluate the safety and efficacy of using bidirectional barbed suture in laparoscopic myomectomy (LM) and total laparoscopic hysterectomy (TLH). METHODS: This was a case series of clinical outcomes following 172 consecutive LM and TLH cases over a 1-year period conducted at a university teaching hospital. It included 172 women (ages 17 to 81), requiring a myomectomy or hysterectomy for symptomatic uterine fibroids, pelvic pain, or abnormal uterine bleeding; 117 women underwent TLH and 55 women underwent LM. Patients were contacted over the phone 6 months after surgery to inquire about number of days of postoperative vaginal bleeding, visits to the hospital due to bleeding, dyspareunia, and other potential complications. RESULTS: For TLH, the average duration of surgery was 109 minutes, average uterine weight was 256 grams (range, 18 to 1242), and average blood loss was 71 mL. In LM, average duration of surgery was 125 minutes, average weight of fibroids was 252 g, average number of fibroids removed was 4.0, and average blood loss was 159 mL. Seven percent of patients and 8% of their partners had persistent dyspareunia after surgery. There were no conversions to laparotomy. CONCLUSIONS: The use of bidirectional barbed suture appears to be safe for closing the vaginal cuff in a TLH and for closing the hysterotomy site during a laparoscopic myomectomy.

Use of a Fibrin Sealant Patch at Cesarean for Conservative Management of Morbidly Adherent Placenta.

Background Morbidly adherent placenta represents a surgical challenge and source of maternal morbidity and mortality. We report the use of a fibrin sealant patch to address hemorrhage associated with a morbidly adherent placenta during cesarean delivery. Case A patient underwent repeat cesarean delivery with complete anterior placenta previa and anticipated morbidly adherent placenta. Bleeding persisted following delivery and removal of the placenta, despite uterine artery embolization. A fibrin sealant patch was applied as an adjuvant intervention to the placental bed and hemostasis was achieved without resorting to a hysterectomy. Conclusion Postpartum hemorrhage is an ongoing leading source of maternal morbidity and mortality. A case is presented in which a fibrin sealant patch provided control of focal placental bed bleeding, allowing removal of a focal morbidly adherent placenta and avoidance of hysterectomy.

Chocolate intake and heart disease and stroke in the Women's Health Initiative: a prospective analysis.

Background: Three recent meta-analyses found significant prospective inverse associations between chocolate intake and cardiovascular disease risk. Evidence from these meta-analyses suggests that such inverse associations may only apply to elderly individuals or those with pre-existing major chronic disease. Objective: We assessed the association between habitual chocolate intake and subsequent incident coronary heart disease (CHD) and stroke, and the potential effect of modification by age. Design: We conducted multivariable Cox regression analyses using data from 83,310 postmenopausal women free of baseline pre-existing major chronic disease in the prospective Women's Health Initiative cohort. Chocolate intake was assessed using a food-frequency questionnaire. Physician-adjudicated events or deaths were ascertained up to 30 September 2013. Results: After exclusions, there were 3246 CHD and 2624 stroke events or deaths, representing incidence rates of 3.9% and 3.2% during 1,098,091 and 1,101,022 person-years (13.4 y), respectively. We found no association between consumption of chocolate and risk of CHD (P for linear trend = 0.94) or stroke (P = 0.24). The results for CHD and stroke combined were similar (P = 0.30), but were significantly modified by age (P for interaction = 0.02). For women age <65 y at baseline, those who ate 1 oz (28.35 g) of chocolate <1/mo, 1 to <1.5/mo, 1.5 to <3.5/mo, 3.5/mo to <3/wk, and ≥3/wk had HRs (95% CIs) of 1.00 (referent), 1.17 (1.00, 1.36), 1.05 (0.90, 1.22), 1.09 (0.94, 1.25), and 1.27 (1.09, 1.49), respectively (P for linear trend = 0.005). No association was apparent for older women. Conclusion: We observed no association between chocolate intake and risk of CHD, stroke, or both combined in participants free of pre-existing major chronic disease. The relation for both combined was modified by age, with a significant positive linear trend and an increased risk in the highest quintile of chocolate consumption among women age <65 y. This trial was registered at clinicaltrials.gov as NCT03453073.

Caffeinated beverage intake and the risk of heart disease mortality in the elderly: a prospective analysis.

BACKGROUND: Motivated by the possibility that caffeine could ameliorate the effect of postprandial hypotension on a high risk of coronary events and mortality in aging, we hypothesized that caffeinated beverage consumption decreases the risk of cardiovascular disease (CVD) mortality in the elderly. OBJECTIVE: The objective of the study was to use prospective cohort study data to test whether the consumption of caffeinated beverages exhibits this protective effect. DESIGN: Cox regression analyses were conducted for 426 CVD deaths that occurred during an 8.8-y follow-up in the prospective first National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. The analysis involved 6594 participants aged 32-86 y with no history of CVD at baseline. RESULTS: Participants aged >or=65 y with higher caffeinated beverage intake exhibited lower relative risk of CVD and heart disease mortality than did participants with lower caffeinated beverage intake. It was a dose-response protective effect: the relative risk (95% CI) for heart disease mortality was 1.00 (referent), 0.77 (0.54, 1.10), 0.68 (0.49, 0.94), and 0.47 (0.32, 0.69) for <0.5, 0.5-2, 2-4, and >or=4 servings/d, respectively (P for trend = 0.003). A similar protective effect was found for caffeine intake in mg/d. The protective effective was found only in participants who were not severely hypertensive. No significant protective effect was found in participants aged <65 y or in cerebrovascular disease mortality for those aged >or=65 y. CONCLUSION: Habitual intake of caffeinated beverages provided protection against the risk of heart disease mortality among elderly participants in this prospective epidemiologic analysis.

A Preliminary Evaluation of Ovine Bladder Mucosal Damage Associated With 2 Different Indwelling Urinary Catheters.

OBJECTIVE: To determine whether a new catheter design with a low-profile, open-ended rounded rather than pointed Foley catheter tip can reduce mucosal damage to the bladder of ewes. METHODS AND MATERIALS: Six ewes were randomly assigned to 1 of 2 indwelling urinary catheters-a 16 Fr Foley catheter or a 16 Fr open-tip CystoSure catheter. After 96 hours, all the animals were sacrificed and their bladder and urethra harvested for analysis. RESULTS: Image analysis of the bladder surfaces demonstrated a significant decrease in the percentage of bladder area covered by ulceration and inflammation in sheep with CystoSure catheters compared with Foley catheters (P < .002) as well as a trend toward less edema (P = .17). Macro-morphologic evaluations were confirmed with immunohistochemical markers of cell proliferation and inflammation. CONCLUSION: In this pilot study, we were able to demonstrate that a new catheter design with an open-ended rounded rather than pointed tip and a reduced balloon base-to-tip profile may reduce mucosal damage to the bladder of ewes. Based on the findings from this trial, we believe this new catheter design with its low-profile, rounded tip may reduce bladder mucosal injury, which is a risk factor for catheter-associated urinary tract infections.

Coffee, diabetes, and weight control.

Several prospective epidemiologic studies over the past 4 y concluded that ingestion of caffeinated and decaffeinated coffee can reduce the risk of diabetes. This finding is at odds with the results of trials in humans showing that glucose tolerance is reduced shortly after ingestion of caffeine or caffeinated coffee and suggesting that coffee consumption could increase the risk of diabetes. This review discusses epidemiologic and laboratory studies of the effects of coffee and its constituents, with a focus on diabetes risk. Weight loss may be an explanatory factor, because one prospective epidemiologic study found that consumption of coffee was followed by lower diabetes risk but only in participants who had lost weight. A second such study found that both caffeine and coffee intakes were modestly and inversely associated with weight gain. It is possible that caffeine and other constituents of coffee, such as chlorogenic acid and quinides, are involved in causing weight loss. Caffeine and caffeinated coffee have been shown to acutely increase blood pressure and thereby to pose a health threat to persons with cardiovascular disease risk. One short-term study found that ground decaffeinated coffee did not increase blood pressure. Decaffeinated coffee, therefore, may be the type of coffee that can safely help persons decrease diabetes risk. However, the ability of decaffeinated coffee to achieve these effects is based on a limited number of studies, and the underlying biological mechanisms have yet to be elucidated.

The Greenberg hysteroscopy speculum: a new instrument for hysteroscopy.

OBJECTIVES: Although the ubiquitous Graves speculum (open-sided or closed) is versatile and familiar, its shortest length is often too long for comfortable manipulation of the newer, pliable, flexible hysteroscopes. The Greenberg speculum is a modification of a Graves speculum with an open side to allow for the removal of instruments while they are still in the vagina. Whereas a standard mediumsized, open-sided Graves speculum measures 110 mm in maximum length, the Greenberg speculum measures only 74 mm. Although the difference between the speculums is only 36 mm in maximum length, this alteration can add considerable ease to placement of both flexible and rigid hysteroscopes in the office or operating room. In this study, we sought to quantify the benefit of this new device by demonstrating that this speculum brings the patient's cervix closer to the provider and reduces the length of unsupported hysteroscope shaft entering the cervical canal. METHODS: We measured the intraspeculum distance from the operator-side opening of the speculum to the external cervical os by using first a standard medium open-sided Graves speculum and then a Greenberg speculum. RESULTS: Use of the Greenberg speculum reduced the mean minimum intraspeculum distance from the extended fingertips grasping a hysteroscope to the external cervical os by an average of 28 mm or 34% compared with a Graves speculum. CONCLUSIONS: We believe this new speculum offers a subtle but distinct advantage over standard speculums for hysteroscopy.