Impact of a multiparameter, ultrasound-based triage on surgical management of adnexal masses.

OBJECTIVE: To prospectively evaluate the accuracy of a multiparameter, ultrasound-based triage and its impact on surgical management of adnexal masses. METHODS: Masses evaluated as normal according to Ferrazzi's sonographic morphological score were considered as being at low risk of malignancy and eligible for laparoscopic treatment without further evaluation. Masses evaluated as abnormal, but without additional risk factors such as ascites, diameter > or = 10 cm, bilaterality, immobility, resistance index < or = 0.6 and serum CA 125 > 35 IU/mL were considered at moderate risk and eligible for laparoscopic evaluation and treatment. Masses with abnormal morphological score and any of these additional risk factors were considered at high risk and treated by laparotomy. The results of pathological examination were obtained for each mass. RESULTS: Two hundred and four (87%) masses were benign and 30 (13%) were malignant. Among 182 low-risk, 19 moderate-risk and 33 high-risk masses, the odds of malignancy were 1 : 90, 1 : 18 and 4.5 : 1, respectively. To calculate the diagnostic accuracy of this algorithm, low- and moderate-risk groups were considered together: the sensitivity was 90%, specificity 97%, positive predictive value 82% and negative predictive value 99%. The new algorithm was significantly more accurate than was morphological score alone (P = 0.0002). Ninety-six percent of benign masses were treated by laparoscopy. All three patients with malignant masses that were incorrectly assigned to laparoscopy underwent laparoscopic adnexectomy and frozen section. CONCLUSIONS: The accuracy of this new algorithm was higher than that of the sonographic morphological scoring system alone. In the present series, it allowed the treatment by laparoscopy of 96% of benign adnexal masses without mismanagement of any cases of ovarian cancer.

A classification of psychological factors leading to violent behavior in posttraumatic stress disorder.

Posttraumatic stress disorder has long been linked to violent behavior. However, the exact nature of that association remains poorly characterized due to the limitations of knowledge in the area of phenomenology, contextual factors, the biology, and the nature of the aggression involved in the disorder. A clear understanding of the genesis of violence in posttraumatic stress disorder can be helpful to those involved in assessing psychiatric-legal issues relevant to the disorder and in its therapeutic management. In this article, we review the potential psychological links between posttraumatic stress disorder secondary to combat exposure and violent behavior and suggest a tentative classification of the main psychological causes of violence in that syndrome.

Identifying the indications for laparoscopically assisted vaginal hysterectomy: a prospective, randomised comparison with abdominal hysterectomy in patients with symptomatic uterine fibroids.

OBJECTIVE: To compare laparoscopically assisted vaginal hysterectomy (LAVH) and total abdominal hysterectomy (TAH) in patients with uterine fibroids. DESIGN: A prospective randomised study. SETTING: The San Paolo Hospital, Milan. POPULATION: Sixty-two patients, who were not suitable for a vaginal hysterectomy, requiring treatment for uterine fibroids. METHODS: Randomisation between LAVH and TAH. Comparison of outcomes on the whole series, patients with uteri < or = 500 g (Group 1) and patients with uteri > 500 g (Group 2). MAIN OUTCOME MEASURES: To establish operating time, blood loss, complications, febrile morbidity, analgesics administration and hospital stay for both treatment approaches. RESULTS: Median uterine weight was 400 g in both LAVH and TAH group. Median operating time was longer for LAVH (135 min compared with 120 min for TAH; P = 0.001), but patients undergoing LAVH had less analgesics administration (23% compared with 77%, P < 0.001) and a shorter median hospital stay (3.8 compared with 5.8 days; P < 0.001). LAVH, when compared with TAH in the two weight subgroups, required a significantly longer operating time only in Group 2, significantly reduced analgesics administration only in Group 1, and significantly reduced hospital stay in both groups. Conversions of LAVH to laparotomy were significantly more frequent in Group 2 (3/11) than in Group 1 (0/20) (P = 0.04). CONCLUSIONS: Compared with TAH, LAVH has advantages in removing uteri weighing < or = 500 g, with comparable operating time, less post-operative pain and shorter recovery. Among uteri weighing > 500 g LAVH showed a shorter recovery, but longer operating time than TAH and a 27% rate of conversion to laparotomy.

Stalking behavior in delusional jealousy.

Stalking behavior has been associated with several mental disorders, both psychotic and non-psychotic. The most frequently associated condition appears to be an individual with primitive personality psychopathology regardless of co-occurring psychotic symptomatology. Among the psychotic symptoms, erotomanic, and jealousy delusions may be the most clinically and torensically relevant. However, delusional jealousy has not been well appreciated in the psychiatric literature as an important contributor to stalking behavior. In this article, we explore the psychiatric, psychosocial, and forensic aspects of stalking in the context of delusional jealousy. We use a case example to highlight important issues in this area.

A comprehensive typology for the biopsychosociocultural evaluation of child-killing behavior.

The homicide of children by their parents has been reported across numerous cultural settings around the world and in many historical periods. A comprehensive and systematic understanding of parental child killing can be optimally obtained through a biopsychosociocultural approach. In this article we present the case of a woman who committed neonaticide. We illustrate the cultural formulation of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and recommend that this formulation has a central role in the evaluation of cultural factors of parents who kill their children.

The dangerousness of persons with delusional jealousy.

Delusional jealousy is an important subject for forensic psychiatry because of its well-known association with violence, especially as directed toward spouses. In this article, we report a study of 20 individuals who suffered from delusional jealousy. Important biopsychosocial parameters, the relation between jealousy and aggression, and directions for future study are explored.

The role of mania in the genesis of dangerous delusional misidentification.

The delusional misidentification syndromes are characterized by a misidentification delusion of the self and/or others. Delusional misidentification syndromes frequently occur in psychotic disorders such as schizophrenia, psychotic disorder due to general medical condition, or psychotic disorder not otherwise specified. On rare occasions these syndromes may be associated with manic states secondary to bipolar disorder, schizoaffective disorder, or general medical conditions. The delusional misidentification syndromes may also be associated with verbal and physical aggression. In this article we present three cases of dangerous delusional misidentification associated with mania. We will discuss the role that mania may have in the genesis of dangerous delusional misidentification.

Delusional misidentification of health care professionals.

Delusional misidentification of others generally involves a person misidentifying others who are emotionally and geographically proximate to that person. Health care professionals may become the objects of delusional misidentification. The present study reviews and analyzes the anglophonic literature on published reports of misidentified health care professionals and adds two new cases. Relevant issues raised when patients misidentify health care professionals are explored, particularly the danger posed by these misidentification delusions.

Laparoscopically assisted vaginal removal of ovarian dermoid cysts.

Dermoid cysts were diagnosed by transvaginal sonography in 19 patients who subsequently underwent laparoscopy to confirm the nature and extent of the lesion and the mobility of the adnexa. Eighteen patients underwent surgery after the ovary was exteriorized through a posterior colpoceliotomy. No intraoperative complications were observed, and sonographic follow-up at 3 and 6 months after surgery showed a normal sonographic ovarian pattern. Laparoscopically assisted vaginal removal of dermoid cysts should be considered as an alternative to laparotomy and operative laparoscopy in cases when adnexal mobility is proven and vaginal extraction is feasible.

The dangerousness of persons with the Othello syndrome.

The Othello syndrome, or delusional jealousy, often raises significant forensic issues, particularly dangerousness. Dangerous patients suffering from the Othello delusion may present with hostility ranging from verbal threats to homicidal acts. We present three cases of individuals suffering from Othello syndrome associated with significant hostility and organic mental factors. We analyze these cases along with Othello syndrome cases culled from the recent anglophonic literature, especially in terms of implications for domestic and public safety.

Nematode egg output and plasma concentration of ivermectin after its administration to red deer (Cervus elaphus elaphus).

Blood and faecal samples were analysed in a study to evaluate the use of ivermectin in red deer hinds (Cervus elaphus elaphus). It was demonstrated that ivermectin, when used at 400 micrograms/kg bodyweight, proved to be more efficient than 200 micrograms/kg bodyweight although positive worm egg counts together with the isolation of lungworm (Dictyocaulus species) larvae were recorded from hinds having received the anthelmintic at the higher dose.

Misidentified political figures: an underappreciated danger.

A series of twelve patients is presented in which each patient suffered from one or more misidentification syndromes and also misidentified one or more political figures. The fact that misidentification syndromes have been associated with physical violence and that the majority of the patients studied had a history of physical violence suggests that these individuals could pose a significant danger of physical harm to others, including political figures. Persons who threaten political figures should be evaluated for misidentification syndromes.

Posttraumatic stress disorder in burn patients.

Posttraumatic stress disorder can occur in burn patients and may delay a patient's recovery. We have described the case of such a patient whose posthospital course was complicated by an untreated, coexisting PTSD.

Lactate metabolism in normal and growth-retarded human fetuses.

Lactate concentration and oxygen content were measured in 21 normal (AGA) and 34 intrauterine growth-retarded (IUGR) infants at the time of elective cesarean section. Maternal lactate and umbilical arterial and venous lactate concentrations were significantly higher in IUGR infants compared with AGA infants. However, when IUGR patients were subdivided according to pulsatility index (PI) measurements of the umbilical artery, no differences were detected between AGA and IUGR patients with PI less than 4 SD, whereas IUGR patients with PI greater than 4 SD had higher lactate concentrations in maternal arterial blood and umbilical arterial and venous blood from both other groups. There was a significant inverse linear relationship between umbilical arterial lactate concentration and umbilical venoarterial differences for both lactate concentrations and for lactate/oxygen quotients. These relationships were significantly different in IUGR fetuses with PI greater than 4 SD compared with AGA and IUGR fetuses with PI less than 4 SD. AGA and IUGR fetuses with PI less than 4 SD have arterial lactate concentrations less than 2 mM even at low oxygen concentrations (O2 content less than 2 mM, O2 saturations less than 20%). At comparable levels of oxygenation, IUGR fetuses with PI greater than 4 SD have a marked lactacidemia. The data suggest that coupling Doppler assessment of flow velocimetry with biochemical analyses of fetal blood can be useful in identifying a subset of IUGR human fetuses at risk of intrauterine hypoxia.

Foetal pulmonary maturation in pregnancies complicated by diabetes and Rh immunization.

In pregnancies complicated by diabetes, foetal lung maturation depends on a good control of maternal blood glucose values. In poorly controlled maternal diabetes, foetal hyperinsulinaemia may cause a delay in pulmonary maturation. There was no single case of respiratory distress syndrome (RDS) in 112 pregnant class B-F diabetic patients that we treated with high doses of insulin. Furthermore, in a controlled randomized trial of diet versus insulin treatment in class A diabetes we found no differences in perinatal mortality in patients with adequate metabolic control. In pregnancies complicated by Rh isoimmunization, determination of phosphatidylglycerol in amniotic fluid is a more reliable marker of foetal lung maturity than is the lecithin/sphingomyelin ratio. The marked decrease in perinatal mortality due to Rh incompatibility observed in recent years depends on several factors including administration of corticosteroids to the mother to prevent RDS, irrespective of whether amniotic fluid parameters indicate foetal lung maturity.

The relationship of maternal and fetal glucose concentrations in the human from midgestation until term.

The relationship between maternal and fetal glucose concentrations was investigated in pregnant women at different gestational ages. Maternal and fetal blood samples were obtained during 14 fetoscopies (17 to 21 weeks), four umbilical cord samples (32 to 36 weeks), nine elective cesarean sections with appropriate for gestational age (AGA) fetuses (35 to 39 weeks) and nine elective cesarean sections with small for gestational age (SGA) fetuses (34 to 37 weeks). A significant linear relationship between maternal and fetal glucose concentrations was demonstrated at midgestation (P less than .001) and at late gestation (P less than .001). At equal maternal concentrations there were no significant differences in fetal glucose concentration between the cord samples obtained in late gestation and those obtained at cesarean section. At midgestation fetal glucose concentration is independent of and may exceed maternal concentration at maternal glucose levels less than 4.44 mmol/L. Furthermore, the relationship between maternal and fetal concentrations at maternal glucose concentrations greater than 4.44 mmol/L is significantly different at midgestation from that at late gestation (P less than .01); at equal maternal concentrations there were higher glucose concentrations in the mid trimester fetus. In late gestation as the maternal glucose concentration increases there is an increase in the maternal arterial-umbilical arterial glucose concentration difference and the umbilical glucose/oxygen quotient (P less than .003) reflecting increased glucose utilization by the fetus. There were no significant differences between AGA and SGA babies with respect to these relationships.