Feasibility and safety of prophylactic uterine artery catheterization and embolization in the management of placenta accreta.

PURPOSE: To evaluate the feasibility and safety of prophylactic uterine artery catheterization and embolization in the management of placenta accreta (PA). MATERIALS AND METHODS: Retrospective chart review was performed of 95 consecutive patients with prenatal suspicion of PA managed in a 10-year period with a strategy that included prophylactic bilateral uterine artery catheterization, delivery of the baby, uterine artery embolization if indicated, and subsequent surgery. Feasibility was defined as catheterization being possible to perform, technical success as embolization being possible when indicated and complete stasis of the vessels achieved, and clinical success as no maternal death or major blood loss. Median gestational age at delivery was 36 weeks (interquartile range, 24-39 wk). RESULTS: PA was confirmed in 79 patients (83%). Feasibility was 97% (92 of 95); in three cases (3%), acute early massive hemorrhage forced emergency delivery without catheterization. Embolization was performed in 83 of 92 patients (87%) to the extent of complete stasis; in the remaining nine, it was unnecessary because spontaneous placental detachment was visualized after fetal delivery (technical success rate, 100%). There were several complications, including bleeding requiring blood transfusion (49%) and bladder surgery (37%), but there were no major complications attributable to the endovascular procedures. There was one minor complication presumably related to embolization (transient paresthesia and decreased temperature of lower limb), with uneventful follow-up. Clinical success rate was 86%, with no maternal deaths, but 14% of patients received large-volume blood transfusion. CONCLUSIONS: Prophylactic uterine artery catheterization and embolization in the management of PA appeared to be feasible and safe in this consecutive series of patients.

Treatment of primary vulvar paget disease with 5% imiquimod cream.

INTRODUCTION: Our objective was to evaluate the efficacy of conservative treatment with imiquimod in Paget vulvar disease. MATERIALS AND METHODS: We describe a case series that includes 10 patients with histopathologic diagnosis of extramammary Paget disease of the vulva, who were treated with 5% imiquimod cream. Of these patients, 3 were treated for recurrent disease and 7 were treated for initial primary disease. The patients applied the cream every other day until the lesions were no longer clinically detected.They were previously instructed on how and where to apply the cream by making them use a mirror while following the physician's directions. RESULTS: Complete clinical and histologic remission of the disease was achieved in 9 patients. The remaining patient had partial histologic response and is still under treatment. The treatment was well tolerated despite moderate irritation. No recurrences were observed during a mean follow-up of 18 months. CONCLUSIONS: On the basis of the results, the authors consider that 5% imiquimod cream could be considered a safe and effective therapeutic option for the treatment of primary vulvar Paget disease. Further studies are needed to determine the real efficacy and safety of 5% imiquimod cream for the treatment of this infrequent disease.

Use of CO2 laser vaporization for the treatment of high-grade vaginal intraepithelial neoplasia.

OBJECTIVE: In a series of cases of high-grade vaginal intraepithelial neoplasia (VaIN) at our institution, to analyze its clinicopathologic characteristics, diagnostic methodology, and therapeutic results obtained with the use of CO2 laser vaporization. MATERIALS AND METHODS: Between January 2003 and December 2009, 28 patients with a diagnosis of high-grade VaIN were treated in our department using CO2 laser vaporization. Of the 28 patients, 7 were lost to follow-up; 21 patients were followed up with cytological examination and colposcopy for therapeutic response. Median follow-up was 25 months (range = 12-78 months). The setting is an urban referral center, a private hospital with a high-grade complexity. RESULTS: Of the 21 patients evaluated, 18 are currently disease free after having undergone a single application of CO2 laser vaporization with a cure rate of 86% (95% CI = 63.7%-97%). Three patients (14%) presented with persistence/recurrence and required a second application. Of these 3 patients, 2 are currently disease free, whereas 1 patient progressed to invasive carcinoma 11 months after a second procedure and was managed with partial colpectomy and pelvic lymphadenectomy. CONCLUSIONS: CO2 laser vaporization was effective for the initial treatment of high-grade VaIN. However, a long-term follow-up is required due to the recurrent character of this disease.

Evaluation of laparoscopic management of gynecologic emergencies by residents.

OBJECTIVE: To evaluate the feasibility of laparoscopic management of women with gynecologic emergencies by the residents and the chief resident in an organized resident training program. METHODS: A retrospective study of patients with gynecologic emergencies who underwent laparoscopic surgery between January 1, 1999, and May 31, 2006 was done. RESULTS: For the 369 patients included, the mean operative time of 74±31.35 minutes was significantly increased by advanced patient age (P<0.001), pelvic inflammatory disease with or without tubo-ovarian abscess (PID±TOA) (P<0.050), the first semester of chief residency (P<0.050), and conversion to laparotomy (P<0.001). Mean length of hospital stay was 40±24 hours. Factors such as advanced patient age (P<0.001), prolonged length of surgery (P<0.001), PID±TOA (P<0.001), first semester of chief residency (P<0.050), conversion to laparotomy (P<0.001), and blood transfusion (P<0.050) significantly increased the length of hospital stay. The conversion rate to laparotomy was 4.6% (n=17), and it was significantly associated with advanced women age (OR 1.11; 95% CI, 1.05-1.17, P<0.001) and PID±TOA (OR 6.04; 95%CI, 2.17-16.62, P<0.001). Postoperative complications were recorded in 3 (0.81%) patients. CONCLUSION: Laparoscopic management of gynecologic emergencies by senior residents and a chief resident within an organized resident training program is feasible. These results reinforce the relevance of a well-structured residency endoscopic training program.

[Allergy to materials used in dental procedures]. / Alergia a materiales utilizados en procedimientos dentales.

OBJECTIVE: To provide a review of the literature regarding the pathological effects of material used in clinical dentistry. DATA SOURCES: PubMed search was performed using the key words: dental biomaterial, odontologic toxicity, odontologic allergy, dental allergens, dental resins. STUDY SELECTION: Articles were selected based on their relevance to this topic. RESULTS: The biomaterials used in orthodontic or dental treatment may lead to alterations of greater biological importance in susceptible or sensitized individuals, and may be able to alter the functions of cells in the mouth, including dentinogenesis and tissue repair; toxicity and mutagenicity have been observed. Some of them release potential antigens or allergens capable of inducing immune or immediate and delayed allergic reactions of diverse severity and extension, which may include extraoral damage. CONCLUSIONS: The number of patients with pathology originated by dental materials has increased. The scarce knowledge about it delays diagnosis. The study of biomaterials used in odontologic procedures and its harmful effect must be encouraged, as well as its pathological manifestations which require more clinical investigation and diffusion, with the aim to give more and better information to dentists, family and allergy physicians so that they can provide prompt and successful care.