To repeat or not to repeat: Radiologists demonstrated more decisiveness than their fellow radiographers in reducing the repeat rate during mobile chest radiography.

INTRODUCTION: Radiologists and radiographers play a complementary role in providing an optimal image quality with decrease radiation dose and proper diagnosis during chest radiographs. We aim Investigate years of experience among radiologists and radiographers on perception of image quality and its impact on repeat rate when evaluating portable pediatric chest radiographs. METHODS: IRB approved retrospective study consisted of randomly selected images (n = 131) of pediatric portable chest radiographs. Images were blindly assessed by four radiologists and four radiographers. Readers were asked to assess qualitative and quantitative image quality by rating: image quality, decision to repeat and image technique. All data was compared employing Pearson's Correlation, Visual grading characteristic (VGC) and Cohens' kappa analyses. RESULTS: Image quality: Radiologists (88.4%) rated images as excellent significantly more than radiographers (11.6%), and radiographers (90.1%) as poor significantly more than radiologists (9.9%) (p < 0.05). Repeat: Radiologists (57%) decided not to repeat images significantly more than radiographers (43%) (p < 0.05). Image technique: Radiologists rated images as acceptable (65%) and excellent (97.7%) significantly more than radiographers (35% and 2.3% respectively) (p < 0.05), whereas radiographers (84%) assessed image technique as poor significantly more than radiologists (16%) (p < 0.05). VGC: radiographers had slightly better qualitative evaluation of image quality than radiologists. An association between image quality (p < 0.002) and repeat decision (p < 0.044) with years of experience was established when comparing years of experience with image assessment rubric, while no association was noted with image technique (p < 0.9). CONCLUSION: Radiologists demonstrated more decisiveness than their fellow radiographers in reducing the repeat rate of portable pediatric chest radiographs. Interestingly, years of experience only seem to affect image technique and image quality assessment among radiologists. IMPLICATIONS FOR PRACTICE: Continuous education of radiographers and close collaboration with radiologists is crucial to achieve optimal image quality and low radiation doses.

First data on Pneumocystis jirovecii colonization in patients with respiratory diseases in North Lebanon.

Pneumocystis colonization may play a role in transmission and local inflammatory response. It was explored in patients with respiratory diseases in North Lebanon. Overall prevalence reached only 5.2% (95% CI 2.13-10.47) but it was higher (17.3%) in the subpopulation of patients with chronic obstructive pulmonary disease (COPD). COPD was the only factor associated with a significantly increased risk of colonization. mtLSU genotyping revealed predominance of genotype 2, identified in five patients (71.4%), including one patient who had co-infection with genotype 3. These first data in North Lebanon confirm Pneumocystis circulation among patients with respiratory diseases and the potential for transmission to immunocompromised patients.

Predictors of intra-operative parathyroid hormone decline in subjects operated for primary hyperparathyroidism by minimally invasive parathyroidectomy.

BACKGROUND: The predictors of intra-operative PTH (IOPTH) decline during minimally invasive parathyroidectomy (MIP) for primary hyperparathyroidism have been but poorly studied. MATERIALS AND METHODS: This retrospective study included 108 patients who underwent MIP for a single adenoma. Serum calcium and phosphorus were measured before surgery and 1 day post-operatively. IOPTH was measured before (intra-operative preincision or PTHt0) and 10 min after removal of the adenoma (PTHt10). The Modification of Diet in Renal Disease (MDRD) equation was used to estimate the glomerular filtration rate. The weight of the adenoma was assessed in all the subjects. RESULTS: The sex ratio female/male was 5.37 with a mean age of 57.3 yr. The mean pre- and postoperative values were for calcium 2.80 and 2.19 mmol/l, respectively (p<0.0001) and for phosphorus 0.90 and 1.16 mmol/l, respectively (p<0.0001). The PTH dropped from a mean value of 184.8 to 50.8 pg/ml 10 min after adenoma resection with a mean drop of 69.7%. Thirteen patients (12%) did not achieve a PTH fall of more than 50%. In a bivariate analysis, age, an MDRD<60 ml/min and weight of adenoma were inversely associated with IOPTH fall (p=0.009, p=0.004, and p<0.001, respectively) while gender, body mass index, hypertension, diabetes, pre-operative phosphorus and calcium had no significant effects. In the multivariate analysis, age, weight of adenoma, and MDRD were still independent negative predictors of the IOPTH fall (p=0.01, p=0.018, and p<0.001, respectively). CONCLUSION: Our results suggest that during MIP the presence of a parathyroid adenoma with a high weight, in an elderly subject or in a subject with altered renal function, will result in a lesser degree of IOPTH fall.

The defensive role of lysozyme in human gingiva in inflammatory periodontal disease.

BACKGROUND AND OBJECTIVE: The presence of lysozyme in human gingiva has not previously been demonstrated. In this study, we looked for evidence for the potential role of lysozyme as a protector of gingival elastic fibres. The objective of this study was also to determine the ex vivo susceptibility to hydrolysis of gingival elastic fibres from patients with or without periodontal disease by human leukocyte elastase and by human cathepsin G. MATERIALS AND METHODS: Using gingival tissue sections from eight control, 10 gingivitis and 10 periodontitis patients, we evaluated the area fraction occupied by gingival elastic fibres (after selective staining) by the use of automated image analysis. In the ex vivo experiments, serial tissue sections from four control, four gingivitis, four young periodontitis and four aged periodontitis patients were submitted to the action of human leukocyte elastase and cathepsin G, after which enzymatic activities were determined by image analysis. Indirect immunodetection of lysozyme was also done on tissue sections for all patients included in this study. RESULTS: Large variations of the area fraction occupied by elastic fibres were observed in human gingiva from young and aged patients with and without periodontal disease. In control and gingivitis patients, leukocyte elastase and cathepsin G had high comparable elastin solubilizing activities. With young and aged periodontitis patients, the two serine proteinases had weak elastin solubilizing activities. Lysozyme appeared to be present at the periphery of gingival elastic fibres in periodontitis patients. CONCLUSION: Lysozyme can be considered an important natural protector of elastic fibres in pathological gingiva.

Pertinent cell population to characterize periodontal disease.

The purpose of this in situ study is to quantify the inflammatory cell subsets and the area fraction (AA%) occupied by collagen fibers in human healthy and diseased (four different stages) gingival connective tissue in order to establish a possible correlation between periodontal disease resulting in collagen breakdown and specific inflammatory cell subsets. Paraffin gingival tissue sections from eight healthy controls (group 0), 10 patients with gingivitis (group 1), 10 patients with moderate periodontitis (group 2) and 10 patients with severe periodontitis (group 3) were immunohistochemically investigated using antibodies against CD-45+, CD-3+, CD-8+, CD-20+, CD-68+, and EMA+ (plasma cells). The AA% occupied by gingival collagen fibers significantly decreased from 54.12% in group (0) to 38.58% in group (1), to 31.87% in group (2), and to 25.46% in group (3). In progressive lesions of periodontal disease, CD-3(+) and CD-8+ cell numbers were increased in early stages within the connective tissue, while CD-20+ cell numbers were increased only in late stages. On the other hand, EMA+, CD-68+ and CD-45+ cell numbers were progressively increased from group (0) to group (3). We demonstrated that CD-68+ monocyte/macrophages, CD-45+ leukocyte common antigen and notably EMA+ plasma cells are pertinently correlated with the severity of periodontal disease and related collagen breakdown.

Dyspareunia in postmenopausal women: a critical review.

BACKGROUND: Dyspareunia, or pain during sexual intercourse, is among the problems most frequently reported by postmenopausal women. Past literature has almost unanimously attributed dyspareunic pain occurring during or after the menopausal transition to declining estrogen levels and vaginal atrophy. OBJECTIVES: To critically review the literature on the prevalence, risk factors, etiology, clinical presentation and treatment of postmenopausal dyspareunia. The present review also examines the traditional and widely held conceptualization of postmenopausal dyspareunia as a direct symptom of hormonal decline. METHODS: Searches of medical and psychological databases were performed for relevant articles and empirical studies. The methodological quality and outcomes of the studies were systematically reviewed. RESULTS: Available empirical evidence suggests that dyspareunia is common in postmenopausal women, and that it is not highly correlated with menopausal status, estrogen levels or vaginal atrophy. Decreasing levels of endogenous estrogen contribute to the development of dyspareunia in postmenopausal women suffering from vaginal atrophy. Hormonal supplementation is beneficial in alleviating their pain. However, a substantial proportion of treated women do not report relief. CONCLUSIONS: Postmenopausal dyspareunia occurring concurrently with vaginal atrophy is strongly associated with a lack of estrogen in the genital tract. However, a significant percentage of postmenopausal women experience dyspareunic pain that is not caused by hypoestrogenism. It is likely that other types of dyspareunia that occur premenopausally are also occurring in postmenopausal women. Research is needed to adequately address this issue. A change in perspective toward a multiaxial pain-focused approach is proposed for future research concerning dyspareunia in postmenopausal women.

Health-related quality of life in postpartum depressed women.

The objectives of this study were a) to evaluate health-related quality of life (HRQoL) among women with postpartum depression, b) examine the association between severity of depressive symptoms and level of impairment in physical and mental HRQoL and c) to identify contributors to physical and mental HRQoL. Seventy-eight women scoring > or =10 on the Edinburgh Postnatal Depression Scale completed the questionnaires measuring: HRQoL (Medical Outcomes Study 36-item short form SF-36), sleep quality, life stress, and social support. All women underwent a cardiovascular stress test to determine aerobic capacity. Compared to Canadian normative data, women experiencing postpartum depressed mood scored significantly lower on all SF-36 domains, as well as on the SF-36 physical and mental component summary score. Severity of depressed mood was not associated to worse physical health status, while poorer aerobic capacity emerged as a significant independent contributor of physical health status. Severity of depressed mood contributed to worse mental health status. After controlling for severity of depressed mood, the occurrence of pregnancy complications, cesarean delivery, poorer sleep quality, life stress, and less social support predicted poorer mental health status.

Pelvic floor muscle functioning in women with vulvar vestibulitis syndrome.

Vaginal sEMG biofeedback and pelvic floor physical therapists' manual techniques are being increasingly included in the treatment of vulvar vestibulitis syndrome (VVS). Successful treatment outcomes have generated hypotheses concerning the role of pelvic floor pathology in the etiology of VVS. However, no data on pelvic floor functioning in women with VVS compared to controls are available. Twenty-nine women with VVS were matched to 29 women with no pain with intercourse. Two independent, structured pelvic floor examinations were carried out by physical therapists blind to the diagnostic status of the participants. Results indicated that therapists reached almost perfect agreement in their diagnosis of pelvic floor pathology. A series of significant correlations demonstrated the reliability of assessment results across muscle palpation sites. Women with VVS demonstrated significantly more vaginal hypertonicity, lack of vaginal muscle strength, and restriction of the vaginal opening, compared to women with no pain with intercourse. Anal palpation could not confirm generalized hypertonicity of the pelvic floor. We suggest that pelvic floor pathology in women with VVS is reactive in nature and elicited with palpations that result in VVS-type pain. Treatment interventions need to recognize the critical importance of addressing the conditioned, protective muscle guarding response in women with VVS.

Large hepatic mesenchymal hamartoma leading to mid-trimester fetal demise.

This report describes a fetus with a large multiloculated cystic liver mass. Two small abdominal cysts were seen on ultrasound at 19 weeks of gestation but the patient was referred to us at 23 weeks, after the mass had grown to 8.0 x 5.6 x 7.0 cm, displacing intra-abdominal organs, heart and diaphragm. There was a small amount of ascites but no hydrops. There was polyhydramnios and a thick hyperechoic placenta. After detailed sonograms and MRI suggested the diagnosis of cystic mesenchymal hamartoma of the liver, cyst decompression was favored and consent was obtained. Unfortunately, absence of fetal cardiac activity was noted on the day of the planned intervention. Autopsy confirmed the diagnosis and demonstrated placental changes consistent with mesenchymal stem villous hyperplasia of the placenta. Large fetal cystic abdominal masses that compress the heart, lungs and other organs may benefit from prenatal decompression. This is the first report of cystic hamartoma of the liver apparent on second-trimester sonography, and the fourth time such a lesion is associated with fetal or neonatal death out of 11 cases diagnosed prenatally.

Neonatal alloimmune thrombocytopenia due to anti-HPA-2b (anti-Koa).

Most severe cases of neonatal alloimmune thrombocytopenia (NAIT) are due to anti-HPA-1a (anti-PlA1) antibodies. We report a case of NAIT due to anti-HPA-2b that resulted in in utero intracranial hemorrhage.A 33-year-old G2P1A0 Caucasian woman had a routine ultrasound at 34 weeks. The fetus appeared to have a left hemispheric hematoma. IVIG, 1g/kg, was started immediately and administered weekly until delivery. One day after receiving the first dose of IVIG, fetal platelet count was 18 x 10(9)/L, and Hb was 116 g/L. Eleven mL of matched platelets compatible by monoclonal antibody immobilization of platelet antigens (MAIPA) assay were transfused in utero, raising the platelet count to 62 x 10(9)/L. Repeat transfusions were done later that week and 1 week later, with pretransfusion counts of 19 x 10(9)/L and 16 x 10(9)/L, respectively. Delivery by C section was done at 35.5 weeks, after the third platelet transfusion. Platelet count at birth was 77 x 10(9)/L. Drainage of the hematoma was performed after transfusion. Testing with a solid phase ELISA revealed reactivity against GP1b/IX. MAIPA testing after platelet treatment with the protease inhibitor leupeptin demonstrated the presence of anti-HPA-2b. On PCR-SSP the mother was HPA-2a homozygous, the father was HPA-2a/2b. Antibodies against the HPA-2b antigen located on the GP1b/IX complex have been reported in rare cases of NAIT. Testing is complicated by proteolytic degradation of the antigen-bearing fragment. Compatible platelets are easily found since approximately 85 percent of donors are HPA-2a/2a.

Vulvar vestibulitis syndrome: reliability of diagnosis and evaluation of current diagnostic criteria.

OBJECTIVE: To assess the reliability of the diagnosis of vulvar vestibulitis as defined by Friedrich and to evaluate the usefulness of Friedrich's criteria in the diagnostic process. METHODS: In a university hospital, 146 women with dyspareunia had two sets of gynecologic examinations involving vulvar pain ratings, took part in structured interviews, and completed the McGill-Melzack Pain Questionnaire. RESULTS: Kappa values for the vulvar vestibulitis diagnosis ranged from 0.66 to 0.68 for inter-rater agreement and from 0.49 to 0.54 for test-retest reliability. Mean vestibular pain ratings ranged from 2.45 at the 12 o'clock site to 7.58 at the 9-12 o'clock site; ratings for all sites correlated significantly between gynecologists. Pain in the labia majora and labia minora was minimal for both sets of examinations, with mean participant pain ratings ranging from 0 to 1.49. Gynecologists' erythema ratings did not correlate significantly with respect to either inter-rater agreement or test-retest reliability. Of Friedrich's three diagnostic criteria, only tenderness to pressure within the vulvar vestibule differentiated dyspareunia patients with and without vulvar vestibulitis. In reference to their coital pain, 88.1% of women with vulvar vestibulitis chose adjectives from the McGill-Melzack Pain Questionnaire describing a thermal quality, and 86.6% chose adjectives describing an incisive pressure sensation. CONCLUSION: Vulvar vestibulitis can be reliably diagnosed in women with dyspareunia. Pain is limited to the vulvar vestibule and can be rated and described in a consistent fashion by these women. Erythema does not appear to be a useful diagnostic criterion.

Outcome of the prenatally diagnosed congenital cystic adenomatoid lung malformation: a Canadian experience.

UNLABELLED: Congenital cystic adenomatoid malformation of the lung (CCAM) is diagnosed by prenatal ultrasonography with an increasing frequency but controversy persists as to its prognosis and prenatal management. METHOD: A multi-institutional study of cases of CCAM diagnosed antenatally identified by ultrasonographers and by a review of hospital charts. RESULTS: We obtained 48 cases from five centers. We estimate the incidence of CCAM at 1:25,000 to 1:35,000 pregnancies. The incidence of voluntary abortions was 15% (7/48), of spontaneous abortions 2% (1/41) and of postnatal death 10% (4/40). One of the postnatal deaths was from trisomy 18. Of the 7 aborted fetuses, 2 had multiple malformations and 1 had severe hydrops and oligohydramnios; the other 4 had a large mass with mediastinal displacement but without hydrops. When pregnancy was allowed to continue, 56% of the lesions regressed spontaneously, even though one third of these had initial progression. In 17 cases (42%) the mediastinal shift corrected itself, sometimes by simple growth of the fetus but most often by a decrease in the size of the lung mass. In 1 fetus, repeated needle decompressions followed by double-pigtail catheter drainage of large cysts allowed regression of hydrops. Despite this, neonatal death occurred from pulmonary hypoplasia. CONCLUSION: CCAM can lead to fetal or neonatal demise from hydrops, lung hypoplasia, prematurity or severe associated malformations, but has a good prognosis in the majority of cases.

Surfactant levels after reversible tracheal occlusion and prenatal steroids in experimental diaphragmatic hernia.

BACKGROUND/PURPOSE: In normal lungs, fetal tracheal occlusion (TO) induces lung growth but decreases the number of type II cells; this is remedied if TO is released (TR) before delivery. In the current study, the effects of TO with or without TR on pulmonary structure and surfactant were assessed in the ovine model in which lung hypoplasia was induced by creation of a diaphragmatic hernia (CDH). METHODS: A left-sided CDH was created in fetal lambs at 80 days gestation; TO was done at 108 days; and TR at 129 days. All ewes were given 1 dose of glucocorticoids at 135 days. At 136 days, the fetus was delivered. Lung weight to body weight ratio, mean terminal bronchiole density, type II cell density, bronchoalveolar lavage fluid (BAL) phosphatidylcholine (PC), BAL surfactant protein A (SP-A) and B (SP-B), and lung tissue SP-A and SP-B were assessed in CDH, CDH with TO, CDH with TO and TR, and controls. RESULTS: CDH lungs were hypoplastic and structurally immature, but had increased type II cell density. TO with or without TR caused lung growth with normalization of lung parenchymal architecture and type II cell density. Although the BAL SP-A and BAL SP-B were similar in all 4 groups, the BAL PC was low in CDH with or without TO or TR. Also, lung tissue SP-B levels were low in CDH with or without TO or TR. However, lung tissue SP-A levels were normal in CDH, but low in CDH with TO with or without TR. CONCLUSIONS: Despite the finding that lung morphology was improved in CDH with TO with or without TR animals, surfactant content and composition remained abnormal. Although surfactant secreted early by the fetus into alveolar spaces contained normal levels of BAL SP-A and BAL SP-B, the low levels of BAL PC and low lung tissue stores of SP-B indicate that these experimental lambs may experience respiratory insufficiency soon after birth. This implies that prophylactic surfactant at birth might be beneficial for CDH.

Regression of antenatally diagnosed localized Caroli's disease.

The authors report on an infant who had a multiloculated cystic lesion located in segment IV of the liver, consistent with Caroli's disease diagnosed, by routine prenatal ultrasound at 25 weeks' gestation, and confirmed by hepatobiliary HIDA scan and computed tomography soon after birth. Because there was no sign of biliary obstruction, the patient was observed initially, with gradual regression of the cysts noted by serial sonograms. Caroli's disease in older children and adults often is associated with recurrent cholangitis and cirrhosis, mandating resection when the disease is unilobar. However, the natural history of Caroli's disease diagnosed in utero is unclear, and a period of observation appears warranted in the asymptomatic patient.

Evaluation of clitoral blood flow by color Doppler ultrasonography.

The feasibility of reliably measuring clitoral blood flow using standard color Doppler ultrasonography was evaluated by two independent assessors in a sample of 40 pre- and post-menopausal women. High positive correlations with no significant mean differences between examiners were found for three major standard blood flow measures including maximum velocity, resistance, and pulsatility indices. With further methodological refinements, ultrasonographic evaluation of clitoral blood flow will be adaptable for clinical and research use and is likely to become the standard physiological measure of female sexual arousal.

Psychosocial correlates of pain attributions in women with dyspareunia.

The relationship between patients' causal attributions for pain and biopsychosocial measures was investigated in a sample of 100 women with dyspareunia. Independently of findings from the gynecological examinations, causal attributions were related to adjustment. More specifically, the women who made psychosocial attributions reported higher pain scores, higher levels of psychological distress, lower levels of marital adjustment, more problems with sexual function, and more frequent reports of sexual assault. The relationship between psychosocial causal attributions for pain and psychosocial distress may be clinically useful in the multidisciplinary treatment of this and other pain disorders, regardless of actual physical pathology.

Prenatal percutaneous needle drainage of cystic sacrococcygeal teratomas.

Prenatal ultrasound (US) permits in utero diagnosis of sacrococcygeal teratoma (SCT), follow-up of tumor size, and the early identification of complications, allowing for a more timely and appropriate delivery. The recommended management of large SCTs is delivery by cesarean section (CS) to prevent dystocia, tumor rupture, hemorrhage, and death. However, even delivery by CS can be difficult, necessitating a large hysterotomy that adds to maternal morbidity. The authors report two cases of cystic SCTs in which prenatal percutaneous drainage allowed for an uncomplicated vaginal delivery. In the first case, a large unilocular cystic SCT was diagnosed at 31 weeks' gestation on prenatal US. The fetal presentation was breech, and the mass was steadily increasing in size, preventing spontaneous version. At 37 5/7 weeks, the cyst was percutaneously drained under US guidance allowing for successful external version. Repeat drainage just before induction of labor permitted a successful vaginal delivery. In the second case, the cystic SCT was percutaneously drained just before induction of labor at full term, again allowing for an uncomplicated vaginal delivery. Prenatal percutaneous needle drainage of cystic SCTs offers an alternative to CS that results in decreased risks for both mother and fetus.

Does vaginismus exist? A critical review of the literature.

The basic strategies and methods for assessing and treating vaginismus were proposed by the early 20th century and have not essentially changed. Etiological theories have changed over time but are not supported by controlled empirical studies. This critical review of the literature disputes the widely held belief that vaginismus is an easily diagnosed and easily treated sexual dysfunction. We propose a reconceptualization of vaginismus as either an aversion/phobia of vaginal penetration or a genital pain disorder.