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.

A negative second trimester triple test and absence of specific ultrasonographic markers may decrease the need for genetic amniocentesis in advanced maternal age by 60%.

OBJECTIVE: A study was conducted to evaluate the sensitivity of combining a second trimester triple test and targeted ultrasound in order to detect Down syndrome in women undergoing amniocentesis over 35 years of age. METHODS: Women over 35 years of age underwent a triple test and an ultrasound examination for chromosomal markers immediately prior to genetic amniocentesis. RESULTS: One thousand and six women were examined. Four hundred and thirty seven were triple test-positive and in 195 cases ultrasonographic abnormalities were observed. Thirteen had Down syndrome and eight had other chromosomal abnormalities. All women with Down syndrome babies were triple test-positive and seven also had ultrasonographic markers. Three of eight women who had babies with chromosomal aberrations other then Down syndrome were also triple test-positive. CONCLUSIONS: The use of the triple test as a screening tool in our population would reduce the number of amniocenteses by 60%, while no cases of Down syndrome would be missed. Ultrasonographic markers have added little to this population. Three non-Down syndrome chromosomal abnormalities and two Down syndrome mosaic cases would be missed by this approach.

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.

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.

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.

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.

Time-dependent effect of tamoxifen therapy on endometrial pathology in asymptomatic postmenopausal breast cancer patients.

Various endometrial lesions were more frequent among asymptomatic postmenopausal breast cancer patients who were treated with tamoxifen for > 48 consecutive months (30.8%) when compared with similar patients who were treated for 6-24 months or for 25-48 months (20.8% and 12.5%, respectively). However, this difference was not statistically significant. There were also no significant differences in the frequency of the various endometrial lesions between these three groups, although endometrial polyps were more frequently found among those treated for > 48 months. Overall, 20.7% of the 164 tamoxifen-treated patients in the study had an endometrial pathology. It can be concluded that there is a slight tendency among those postmenopausal patients who have been treated for > 48 consecutive months to have a higher frequency of endometrial lesions.

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.

Continuous tamoxifen treatment in asymptomatic, postmenopausal breast cancer patients does not cause aggravation of endometrial pathologies.

Adjuvant tamoxifen therapy for breast cancer patients has been found to be associated with various endometrial pathologic conditions, including endometrial cancer. This preliminary case control study evaluated whether prolonged and continuous exposure to tamoxifen in the menopause may aggravate existing endometrial pathologies. Two vaginal ultrasound evaluations of endometrial thickness and histologic findings of two endometrial biopsies, performed 18 months apart, were evaluated for 25 asymptomatic, postmenopausal breast cancer patients who were continuously treated with tamoxifen. In the first endometrial biopsy, 4 patients (16.0%) were found to have endometrial pathologies: 2 patients had proliferative endometrium, 1 had hyperplastic endometrium, and 1 had an endometrial polyp. In the second endometrial biopsy, none of these patients showed any endometrial pathologies. Another patient (4.0%) with no endometrial pathology in the first visit had endometrial hyperplasia in the second visit. None of the patients developed endometrial cancer, and generally there was no increase in ultrasonographically-measured endometrial widths. The results of this preliminary study may suggest that there is no increased risk of development of endometrial pathologies during an additional 18 months of continuous tamoxifen therapy nor is there aggravation of already existing endometrial pathologies.

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.

Endometrial changes with tamoxifen: comparison between tamoxifen-treated and nontreated asymptomatic, postmenopausal breast cancer patients.

Endometrial thickness, as evaluated by vaginal ultrasonography, and endometrial histologic findings, as well as demographic characteristics, health habits, and risk factors for endometrial cancer, were compared between 93 asymptomatic postmenopausal breast cancer patients who had been on tamoxifen treatment and 20 patients who had not. The mean ultrasonographic endometrial thickness in the women on tamoxifen treatment was 13.1 +/- 10.4 mm, which was significantly thicker than the 4.0 +/- 3.2 mm found in the nontreated women (P = 0.001). The frequency of endometrial pathological findings was remarkably high (35.5%) among the tamoxifen-treated patients, compared with nontreated patients (20.0%), with a P value of 0.058 and an odd ratio of 4.6. Thus, it is suggested that the remarkably high prevalence of pathological endometrial changes was due to the continuous and unopposed exposure of the endometrium to tamoxifen.

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.

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.

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.

Endometrial changes in postmenopausal women treated with tamoxifen for breast cancer.

OBJECTIVE: To evaluate whether risk factors, other than tamoxifen, can be identified for the development of endometrial pathologies in postmenopausal breast cancer patients treated with tamoxifen. DESIGN: A cross-sectional study. SETTING: Department of Obstetrics and Gynaecology and Oncology Clinic, Sapir Medical Center, Kfar Saba, Israel. SUBJECTS: 77 asymptomatic postmenopausal women, treated with tamoxifen for breast cancer. Of these, 55 had no endometrial tissue and 22 had endometrial tissue obtained by biopsy. MAIN OUTCOME MEASURES: Demographic characteristics, health habits, risk factors, vaginal ultrasonographic evaluations of endometrial thickness and texture, and histologic evaluations of endometrial biopsies. RESULTS: Overall, there was a high rate (29%) of endometrial pathological change among the 77 asymptomatic postmenopausal women. There were no significant statistical differences in the features tested between the two groups. CONCLUSION: It is impossible to predict which postmenopausal women will develop pathological endometrial changes after treatment with tamoxifen and thus a routine periodic endometrial sampling-follow up is suggested for all postmenopausal women being treated with this agent.

Ultrasonographic evaluation of the endometrium and correlation with endometrial sampling in postmenopausal patients treated with tamoxifen.

Seventy-two asymptomatic, postmenopausal women treated with tamoxifen for breast cancer were studied prospectively with vaginal ultrasonography, followed by endometrial sampling. Seventy-one patients demonstrated an endometrial echo of more than 5 mm, and one displayed an endometrial echo of less than 5 mm. No patient with an endometrial echo of less than 5 mm displayed any endometrial pathology. Different endometrial pathologic conditions were found when the endometrial echo was over 5 mm. When classifying those patients whose ultrasonic endometrial widths were wider than 5 mm, on the basis of different endometrial histologic findings, no obvious correlation was found between the various pathologic endometrial findings and endometrial thickness. Thus, a "thicker" endometrial sonographic image did not necessarily correlate with pathologic endometrial findings. When ultrasonic endometrial thickness of 5 mm was considered the upper limit of normal, the sensitivity of ultrasonography in correlating to positive histologic findings was 91% and the specificity was 96%. These findings suggest that there is good correlation between endometrial width measured by ultrasonographic assessment and histologic findings.

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.