The impact of a nationwide hands-on workshop on the diagnostic rates and management of obstetrical anal sphincter Injuries in Israel.

AIM: The aim was to evaluate the influence of a half day, hands-on, workshop on the detection and repair of obstetric anal sphincter injuries (OASIs). METHOD: Starting in February 2011, hands-on workshops for the diagnosis and repair of OASIs were delivered by trained urogynaecologists in departments of tertiary medical centres in Israel. The structure of the hands-on workshop resembles the workshop organized at the International Urogynecological Association annual conferences. Participants included medical staff, midwives and surgical residents from each medical centre. We collected data regarding the rate of OASIs, 1 year before and 1 year following the workshop, in 11 medical centres. The study population was composed of parturients with the following inclusion criteria: singleton pregnancy, vertex presentation and vaginal delivery. Pre-viable preterm gestations (< 24 weeks), birth weight < 500 g, stillborn, and those with major congenital anomalies, multifoetal pregnancies, breech presentations and caesarean deliveries were excluded from the analysis. RESULTS: In the reviewed centres, 70 663 (49.3%) women delivered prior to the workshop (pre-workshop group) and 72 616 (50.7%) women delivered following the workshop (post-workshop group). Third- or fourth-degree perineal tears occurred in 248 women (0.35%) before the workshop, and in 328 (0.45%) following the workshop, a significant increase of 28.7% (P = 0.002). The increase in diagnosis was significant also in women with third-degree tears alone, 226 women (0.32%) before the workshop and 298 (0.41%) following the workshop, an increase of 28.3% (P = 0.005). CONCLUSION: The detection rate of OASIs has significantly increased following the hands-on workshop. The implementation of such programmes is crucial for increasing awareness and detection rates of OASI following vaginal deliveries.

The effect of rLH supplementation to the GnRH-antagonist protocol on endocrine dynamics in the advanced reproductive age.

PURPOSE: To explore serum endocrine dynamics, specifically LH levels, following rLH supplementation to rFSH following GnRH-antagonist treatment in the advance reproductive age. METHODS: Women were prospectively and similarly treated employing rFSH and the flexible GnRH-antagonist protocol, while rLH was supplemented only to the study group. Serum FSH, LH, E2, and P were evaluated throughout the follicular phase. Three strategies were a priori planned to examine endocrine dynamics among women enrolled. RESULTS: While serum LH drop were similar before GnRH-antagonist stimulation, it dropped more times in the control group compared to the study group. Among women receiving rFSH only, serum LH levels dropped ≤2, ≤1 and ≤0.5 mIU/mL in 71.4, 46.4, and 28.6% of cases, while this occurred only in 38.7% (P = 0.01), 6.5% (P = 0.0004) and 3.2% (P = 0.007) of women receiving combined rFSH and rLH treatment, respectively. The same trend was found when serum LH dropped in at least two occasions following the GnRH-antagonist administration. Conversely, serum LH diagrams throughout the follicular phase did not differ between the two groups. Furthermore, individual area under the curve values of LH, E2, and P was similar between the two groups following GnRH-antagonist initiation. CONCLUSIONS: Different strategies to explore LH dynamics following the GnRH-antagonist administration have resulted in diverse results, implying the need for a consensus definition of LH threshold for adequate folliculogenesis and steroidogenesis. Such action would pave the way for understanding which groups of patients may benefit from rLH supplementation.

Inhibition of inflammation may enhance nitric oxide availability in patients undergoing bariatric surgery for weight loss.

BACKGROUND: Weight loss surgery is the most effective treatment for morbid obesity. The mechanisms underlying the beneficial cardiovascular effects are poorly understood, although inhibition of inflammatory markers has been demonstrated. We hypothesized that anti-inflammatory and antioxidative stress reactions are responsible for the beneficial effects of bariatric surgery that have been shown in clinical trials. METHODS: The inflammatory system was studied by measuring mRNA levels of E-selectin, tumour necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) and in a cell line (HUVEC-CS) of human umbilical vein endothelial cells that were incubated for 4 h with pools of serum, collected before and 3 months after surgery, from 20 women who underwent bariatric surgery for weight loss. The oxidative stress pathway was examined by mRNA expression of NADPH oxidase (P22(phox) ), paraoxonase (PON2), superoxide dismutase 2 (SOD2), glutathione peroxidase (GPx) and catalase following incubation of the cells for 4 h with serum pools. The nitric oxide (NO) pathway was studied by measuring mRNA levels of inducible NOS and endothelial NOS and by determining nitrite and nitrate levels. To study the functional behaviour of endothelial cells under stress, primary human umbilical vein endothelial cells (PECs) were incubated with the serum pools for 48 h, with lipopolysaccharide (LPS) for the last 4 h. RESULTS: The inflammatory system: incubation of HUVEC-CS cells with serum from women who underwent bariatric surgery led to a significant decrease in mRNA expression of E-selectin and IL-6 postsurgery. Stimulation of PECs with LPS in the presence of serum from women who underwent bariatric surgery caused a more significant difference in E-selectin and TNF-α mRNA expression before and after surgery. The antioxidant system: incubation of HUVEC-CS cells with serum from women who underwent bariatric surgery did not lead to any difference in mRNA expression of P22(phox) , PON2, SOD2, GPx or catalase. Stimulation of PECs with LPS showed that obese women had higher levels of P22(phox) , PON2 and the antioxidant enzymes SOD2, GPx and catalase before and after surgery, compared to the control group. The NO pathway: HUVEC-CS cells incubated with serum from women who underwent bariatric surgery secreted higher nitrite/nitrate levels compared to presurgery serum (P = 0.04). CONCLUSIONS: Inhibition of inflammation and enhanced availability of NO 3 months after bariatric surgery could partly explain the beneficial effects of surgery for weight loss.

Teaching internal medicine in the community.

BACKGROUND: Teaching Internal Medicine is mainly hospital-based. Chronic diseases are treated mostly in community-based ambulatory care. This study describes our experience during the first year of teaching Internal Medicine in the community, with a focus on chronic disease management. METHODS: This was an observational study describing the content of clinical exposure and the feedback from students after a two-week clerkship in community health centers. RESULTS: Over a period of three months, 54 students spent two weeks in health centers singly or in pairs. The disciplines covered were: Endocrinology, Gastroenterology, Pulmonology, Rheumatology and Geriatrics. In their feedback, the students most frequently noted knowledge acquired in the management of diabetes, infectious diseases and cardiology. The teaching content was determined by the case-mix of patients. The spectrum of conditions was wide. Students who were used to more structured hospital-based study found it difficult to cope with this mode of learning by discovery. DISCUSSION: Future research should concentrate on the transition between the different modes of learning as students move from the hospital to the community setting.

Glycemic control and clinic attendance of emerging adults with type 1 diabetes at a transition care clinic.

BACKGROUND: Emerging adulthood is a challenging period for diabetes management. Our aim was to determine whether a dedicated transition clinic for emerging adults with type 1 diabetes can improve glycemic control and visit attendance. METHODS: An observational study of 53 emerging adults (30 males) treated during 2010-2014 in a newly established transition clinic. The clinic was operated jointly by pediatric and adult endocrinologists and included a transition coordinator. Data collected included the source of referral, HbA1c levels, frequency of visit attendance, and acute complications. For 27 patients who had attended the pediatric clinic at the same medical center, data from up to 2 years preceding the transition were also collected. Patients filled the Diabetes Quality of Life-Youth questionnaire at the transition and 1 year later. RESULTS: Mean ± SD age at the transfer to the transition clinic was 22.1 ± 2.7 years; mean disease duration was 8.4 ± 5.0 years. Follow-up duration at the transition clinic was 1.2 ± 1.1 years. Mean HbA1c levels decreased from 67 mmol/mol (95 % CI 63-72) [8.3 % (95 % CI 7.9-8.7)] at transfer to 57 mmol/mol (95 % CI 52-63) [7.4 % (95 % CI 6.9-7.9)] after 1 year (p < 0.001). Thirty-six patients (68 %) attended three or more visits during their first year in the transition clinic. The impact of diabetes on quality of life, disease-related worries, and life satisfaction did not change significantly during 1-year attendance in the transition clinic. CONCLUSIONS: A dedicated transition clinic for emerging adults, with tailored support according to the developmental needs of emerging adulthood, showed improved glycemic control and visit attendance.

The use of continuous glucose monitoring systems in a pediatric population with type 1 diabetes mellitus in real-life settings: the AWeSoMe Study Group experience.

AIMS: The aim of the study was (a) to compare annual glycemic control in pediatric patients with type 1 diabetes mellitus (T1DM) who used a healthcare-funded continuous glucose monitoring system (RT-CGMS) to that of those who performed self-monitoring blood glucose (SMBG) only, in a real-life setting, and (b) to define parameters associated with compliance and glycemic control. METHODS: A total of 149 youth with T1DM (52.3 % females), mean age 11.8 ± 3.6 years, and 83 in the CGMS group were followed prospectively for 12 months. Glycemic control parameters and compliance to RT-CGMS were assessed periodically. RESULTS: Glycemic parameters did not differ significantly between the groups during follow-up periods. The time spent with RT-CGMS decreased and only 38 % used it for more than 75 % of the time during the 12 months (consistent users). Mean HbA1c decreased by 0.27 % in consistent users and increased by 0.21 % among intermittent users (used RT-CGMS less than 75 % of time), p = 0.013. Consistent users were younger 10. 6 ± 4.2 vs. 12.5 ± 3.6, p = 0.07, and had higher frequency of SMBG at baseline, 10.6 ± 4.9 vs. 6.3 ± 2.8, p = 0.011. CONCLUSIONS: The adoption of RT-CGMS was low, even in a healthcare system that funds its use. Caregivers should consider patient characteristics when recommending RT-CGMS use.

Increased progesterone/estradiol ratio in the late follicular phase could be related to low ovarian reserve in in vitro fertilization-embryo transfer cycles with a long gonadotropin-releasing hormone agonist.

OBJECTIVE: To gain insight into the physiologic as well as the clinical significance of premature luteinization in the long gonadotropin-releasing hormone agonist (GnRH-a) cycles and to evaluate whether it may be a manifestation of low ovarian reserve. DESIGN: Prospective evaluation. SETTING: A university-affiliated reproductive medicine unit. PATIENT(S): Seventy-six consecutive infertile women. INTERVENTION(S): The long GnRH-a protocol was used for IVF-ET treatment. MAIN OUTCOME MEASURE(S): Women in the study were prospectively evaluated in their first cycle of treatment and were divided into those with (study group) or without premature luteinization (control group). Premature luteinization was defined as P/E2 ratio of more than 1 on the day of hCG administration. RESULTS(S): Thirty-one (41%) of the women in the study demonstrated premature luteinization. Patients' characteristics were comparable between the two groups. Late follicular P/E2 ratio was significantly and considerably higher in the study as compared to the control group, 2.4 +/- 1.7 and 0.7 +/- 0.2, respectively. Ovarian reserve parameters including day 3 FSH, E2 level on hCG day, total amount of hMG, number of follicles, oocytes, and embryos were significantly inferior in the study as compared to the control group. P levels on hCG day were significantly higher in the study as compared to the control group, 1.9 +/- 0.7 ng/mL and 1.2 +/- 0.6 ng/mL, respectively. However, LH levels on hCG day did not differ between the groups, 1.4 +/- 0.7 mIU/mL and 1.2 +/- 0.7 mIU/mL, respectively. The clinical pregnancy rate was significantly lower in the premature luteinization group as opposed to controls, 13% and 42%, respectively. CONCLUSION(S): Premature luteinization, defined as late follicular P/E2 >1, in long GnRH-a cycles seems to adversely affect clinical outcome. Our findings in this setting support the notion that premature luteinization could be related to low ovarian reserve and that this manifestation is not necessarily an LH-dependent event.

Premature luteinization: could it be an early manifestation of low ovarian reserve?

OBJECTIVE: To gain insight into the physiologic significance of premature luteinization and to evaluate whether it could be a manifestation of low ovarian reserve. DESIGN: Retrospective evaluation. SETTING: Reproductive medicine unit. PATIENT(S): Thirty-one consecutively seen women with normal ovulation and unexplained infertility. INTERVENTION(S): Induction of superovulation with hMG coupled with synchronized IUI. A GnRH agonist was not used during the study. MAIN OUTCOME MEASURE(S): Premature luteinization was defined as a progesterone/estradiol ratio of > 1 on the day of hCG administration. Patients were evaluated during their first cycles of hMG treatment and then were divided into those with (study group) and those without (control group) premature luteinization. The ovarian reserve parameters were compared between the two groups. RESULT(S): Nineteen of the 31 patients with unexplained infertility demonstrated premature luteinization. Patient characteristics were similar between the study and control groups. Mean (+/- SD) day 3 FSH levels were 8.2 +/- 3.3 and 6.6 +/- 1.7 mIU/mL in the study and control groups, respectively. Mean (+/- SD) day 3 estradiol levels were significantly higher in the study than in the control group (74 +/- 49 pg/mL vs. 30 +/- 17 pg/mL, respectively). Mean (+/- SD) estradiol levels on the day of hCG administration also differed significantly between the study and control groups (760 +/- 539 pg/mL vs. 1,568 +/- 675 pg/mL, respectively). Likewise, the number of follicles that were > or = 15 mm on the day of hCG administration was significantly lower in the study than in the control group (2.9 +/- 1.5 vs. 4.3 +/- 1.3, respectively). The total dose of hMG and duration of administration were similar in the two groups. The clinical pregnancy rates after four cycles of treatment were 15.8% and 41.7% in the study and control groups, respectively. CONCLUSION(S): This preliminary work suggests that, in cycles that are not treated with a GnRH agonist, signs of premature luteinization in patients with unexplained infertility could be an early manifestation of low ovarian reserve. It appears that hMG treatment in this group of patients could uncover the pathogenesis of their infertility.

Two-day IUI treatment cycles are more successful than one-day IUI cycles when using frozen-thawed donor sperm.

The difference in pregnancy rates following intrauterine insemination (IUI) for 1 vs. 2 days in the periovulatory period has been reported as either inconsequential or favoring the use of two consecutive inseminations, 24 hours apart. Our study compared the monthly fecundity and cumulative probability of pregnancy in a large group of women (n = 123) undergoing controlled ovarian hyperstimulation and 1- or 2-day inseminations with donor sperm prepared from frozen-thawed samples. All patients underwent controlled ovarian hyperstimulation employing either clomiphene citrate in 217 cycles or human menopausal gonadotropin in 185 cycles. The choice of single or double insemination was decided by the day of the week each patient received human chorionic gonadotropin for ovulation induction. Approximately 80% of all the patients underwent both single and double insemination treatments during the 2.5-year study period. Ninety-three patients received single inseminations in 180 cycles, whereas 103 patients received double inseminations in 222 cycles. Nine clinical pregnancies were achieved in the 1-day group (5% per cycle, 9.7% per patient), while 39 pregnancies occurred in the 2-day group (17.9% per cycle, 37.9% per patient). Two and five spontaneous abortions occurred in the 1- and 2-day groups, yielding take-home baby rates of 3.9% per cycle (7.5% per patient) and 15.3% per cycle (33.0% per patient), respectively. The cumulative probability of conception over 15 cycles of treatment was consistently twice as high or higher for the 2-day group. The results of this study support the use of 2-day IUI treatment cycles when using frozen-thawed donor sperm.

Acute adrenal insufficiency during pregnancy and puerperium: case report and literature review.

UNLABELLED: Acute adrenal dysfunction during pregnancy is rare. Nevertheless, adrenal insufficiency can present as an adrenal crisis, and may be life threatening. There is a wide range of clinical symptoms and signs, and the differential diagnosis is challenging. A full adrenal and pituitary evaluation, both structural and hormonal, must be performed to reach the correct diagnosis, and appropriate treatment must not be delayed. A case is presented of acute adrenal insufficiency that occurred 24 hours after a cesarean delivery. The initial symptoms included hypoglycemic seizures and coma. The workup, both hormonal and structural, revealed isolated adrenocorticotrophic hormone deficiency. This considers this case and reviews the differential diagnosis, diagnostic workup, and the treatment of adrenal dysfunction in pregnancy and the puerperium, as well as the obstetric outcome in women suffering from this disorder. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader will be able to understand the various presentations of hypopituitarism, the various etiologies of this condition, and the appropriate work up and management of a patient with hypopituitarism.

Lymphoma and leukemia complicating pregnancy.

The hematologic malignancies rarely complicate pregnancy. Pregnancy is not thought to affect the course of either Hodgkin's lymphoma, non-Hodgkin's lymphoma, or the leukemias. The prognosis worsens only if there is a delay in diagnosis or treatment. Both chemotherapy and radiotherapy have been administered during pregnancy with favorable results.

Endometrial ablation using hysteroscopic instillation of hot saline solution into the uterus.

OBJECTIVE: To evaluate the clinical effectiveness and safety of endometrial ablation by hysteroscopic instillation of hot saline using the Hydro-Therm-Ablator (HTA) system. METHODS: A total of 14 patients with menorrhagia, underwent the HTA procedure under general anethesia. Follow up of 9-18 months is reported. Three patients had undergone tubal ligation years before the procedure and one underwent it immediately after HTA at the same session. RESULTS: One procedure was cancelled due to technical problems, and roller-ball ablation was performed. There were no procedure related complications. A total of 11 patients reported significant reduction in bleeding, or amenorrhea, 9-18 months after the HTA procedure. One patient, although eumenorrheic after the ablation, considered the procedure a failure and requested hysterectomy. One patient with menorrhagia 3 months after the procedure, had a second HTA ablation and is now amenorrheic. CONCLUSIONS: This series of patients who underwent HTA ablation had successful reduction of menorrhagia to oligomenorrhea or amenorrhea.

Otitis media with effusion--complications after treatment.

In this work we have followed 64 patients suffering from OME (otitis media with effusion) who had ventilating tubes (VT) introduced between 1967 and 1971. In 82 ears (78.8 per cent of cases) recovery and improvement were observed. In one of the ears, a long-standing perforation was noted. In 11 cases (10.5 per cent), after more than 10 years, further treatment and follow-up were mandatory; these patients suffered from some attic disease. In eight cases the attic retraction was under control; in three other cases the disease progressed in spite of treatment, and they underwent surgery.

Diabetes in pregnancy: efficacy and cost of hospitalization as compared with ambulatory management--a prospective controlled study.

BACKGROUND: Pregnant diabetic women are often subjected to frequent and prolonged hospitalizations to assure tight glycemic control, but in recent years attempts have been made at ambulatory control. The financial and social advantages of ambulatory management are obvious, but no report to date has prospectively compared its efficacy with that of hospitalization. OBJECTIVES: To evaluate the efficacy and cost of ambulatory care as compared to repeated hospitalizations for management of diabetes in pregnancy. METHODS: We conducted an 8 year prospective controlled study that included 681 diabetic women, experiencing 801 singleton pregnancies, with commencement of therapy prior to 34 gestational weeks. During 1986-1989, 394 pregnancies (60 pregestational diabetes mellitus and 334 gestational diabetes mellitus) were managed by hospitalization, and for the period 1990-1993, 407 pregnancies (61 PGDM and 346 GDM) were managed ambulatorily. Glycemic control, maternal complications, perinatal mortality, neonatal morbidity and hospital cost were analyzed. RESULTS: There was no difference in metabolic control and pregnancy outcome in women with PGDM between the hospitalized and the ambulatory groups. Patients with GDM who were managed ambulatorily had significantly lower mean capillary glucose levels, later delivery and higher gestational age at induction of labor as compared to their hospitalized counterparts. In this group there were also lower rates of neonatal hyperbilirubinemia, phototherapy and intensive care unit admissions and stay. The saved hospital cost (in Israeli prices) in the ambulatory group was $6,000 and $15,000 per GDM and PGDM pregnancy, respectively. CONCLUSIONS: Ambulatory care is as effective as hospitalization among PGDM patients and more effective among GDM patients with regard to glycemic control and neonatal morbidity. This is not only more convenient for the pregnant diabetic patient, but significantly reduces treatment costs.

[Tuberculous meningitis].

2 cases of tuberculous meningitis are presented, 1 in a 54-year-old woman who had immigrated to Israel from Turkey 36 years before, and the other in a 10-year-old girl who recently immigrated from Ethiopia. Since diagnosis is difficult and prompt antituberculous treatment is life-saving, treatment may be instituted before the bacteriological diagnosis is established. A short term treatment of 9 months and a combination of rifampicin and isoniazid were successful in our patients.

[Ultrasonic estimation of fetal weight].

To generate formulas to estimate fetal weight on the basis of sonographic measurements, 226 pregnant women were scanned within 3 days of delivery. Measurements included: biparietal diameter, head circumference and area, abdominal circumference and area, and femoral length. The contribution of each parameter to the estimation of fetal weight was tested by stepwise regression analysis. The best dependent variable was found to be the log of weight. The formula based on cranial and abdominal parameters proved to be inaccurate, especially when fetal weight was less than 2500 g. The addition of femoral length improved weight estimation, with a multiple r of 0.95174. The addition of gestational age led to even more accurate formulas. The most accurate found was based on biparietal diameter, abdominal circumference, femoral length and gestational age, with a multiple r of 0.95651 and an absolute mean error of 7.976 +/- 5.657%. It also produced better weight estimates at the 2 extremes of fetal weight.

[Toxocariasis in Emek Israel].

Toxocariasis is a rare zoonotic disease in Israel. It usually affects children under the age of 10. Toxocara canis and Toxocara catis are common parasites among dogs and cats which affect man when he ingests the eggs of these helminths. We describe 3 children with different clinical presentations of the infestation. A 6-year-old boy had pain in the muscles of the limbs and diffuse patches in the right lower lobes on X-ray; a 7-year-old girl presented with a limp; and a 3-year-old boy had abdominal pain and a maculopapular rash covering the whole body. All 3 had eosinophilia. They illustrate the importance of toxocariasis in the differential diagnosis of eosinophilia.