What Are the Advantages of 3D Cameras in Gynaecological Laparoscopy?

Introduction Minimally invasive operative techniques are being used increasingly in gynaecological surgery. The expansion of the laparoscopic operation spectrum is in part the result of improved imaging. This study investigates the practical advantages of using 3D cameras in routine surgical practice. Materials and Methods Two different 3-dimensional camera systems were compared with a 2-dimensional HD system; the operating surgeon's experiences were documented immediately postoperatively using a questionnaire. Results Significant advantages were reported for suturing and cutting of anatomical structures when using the 3D compared to 2D camera systems. There was only a slight advantage for coagulating. The use of 3D cameras significantly improved the general operative visibility and in particular the representation of spacial depth compared to 2-dimensional images. There was not a significant advantage for image width. Depiction of adhesions and retroperitoneal neural structures was significantly improved by the stereoscopic cameras, though this did not apply to blood vessels, ureter, uterus or ovaries. Conclusion 3-dimensional cameras were particularly advantageous for the depiction of fine anatomical structures due to improved spacial depth representation compared to 2D systems. 3D cameras provide the operating surgeon with a monitor image that more closely resembles actual anatomy, thus simplifying laparoscopic procedures.

Economic modeling of sealing primary molars using a "value of information" approach.

The objective was to evaluate 2 primary molar sealant strategies for publicly insured children using an "expected value of perfect information" (EVPI) approach. We converted a 10,000-observation tooth-level cost-effectiveness simulation model comparing 2 primary molar sealant strategies - always seal (AS) and standard care (SC) - with a 1,250-observation child-level model. Costs per child per restoration or extraction averted were estimated. Opportunity losses under the AS strategy were determined for children for whom SC was the optimal choice. We determined the EVPI by multiplying mean opportunity losses by the projected incident population of publicly insured 3-year-olds in the US over 10 years with costs discounted at 2%. All analyses were conducted under assumptions of high and low intrachild correlations between at-risk teeth. The AS strategy cost $43.68 over SC (95% CI: -$5.50, $92.86) per child per restoration or extraction averted under the high intrachild correlation assumption and $15.54 (95% CI $7.86, $23.20) under the low intrachild correlation. Under high intrachild correlation, mean opportunity losses were $80.28 (95% CI: $76.39, $84.17) per child, and AS was the optimal strategy in 31% of children. Under low correlation, mean opportunity losses were $14.61 (95% CI: $12.20, $17.68) and AS was the optimal strategy in 87% of children. The EVPI was calculated at $530,813,740 and $96,578,389 (for high and low intrachild correlation, respectively), for a projected total incident population of 8,059,712 children. On average, always sealing primary molars is more effective than standard care, but widespread implementation of this preventive approach among publicly insured children would result in large opportunity losses. Additional research is needed to identify the subgroups of publicly insured children who would benefit the most from this effective and potentially cost-saving public health intervention.

Pathophysiology of Bone Remodelling and Current Therapeutic Approaches.

Different metabolic bone parameters such as RANK (receptor activator of nuclear factor-κB), RANK ligand (receptor activator of nuclear factor-κB ligand) and OPG (osteoprotegerin) control physiological bone remodelling. The pathophysiology of these factors in bone diseases and osseous metastases is becoming clearer. In metastatic breast cancer, osteolytic bone metastases are the result of increased osteoclastic activity caused either by increased RANK ligand or decreased OPG expression of metastatic osseous tumour cells. These findings may lead to new therapeutic options for the treatment of breast cancer patients. The aim of this work is to provide an overview of physiological bone remodelling and of the interaction between tumour cells and bone environment. Current therapy approaches and the mechanisms of action of drugs are described.

RANK, RANKL and OPG Expression in Breast Cancer - Influence on Osseous Metastasis.

In women, malignant breast tumours are among the most common malignant diseases in Europe. In advanced breast cancer, the risk of bone metastasis increases to 65-75 %. The discovery of the physiological bone metabolism parameters RANK (receptor activator of nuclear factor-κB), RANKL (receptor activator of nuclear factor-κB ligand) and OPG (osteoprotegerin) as well as their pathophysiological involvement in bone-related diseases is the subject of new therapeutic strategies. The formation of osteolytic bone metastasis requires increased osteoclast activity. Activation of osteoclasts by excessive direct RANKL or reduced OPG expression of osseous metastatic tumour cells remains to be elucidated. More than 50 % of primary breast cancer cells express OPG and RANK, while RANKL could be detected only in 14-60 %. Increased OPG concentrations in the serum of patients with bone metastases have been shown in several studies, whereas the RANKL results are described in an opposite manner. The use of OPG as a biomarker for the detection of osteolytic bone metastases is not consistent and needs to be proved in further studies. Increased RANKL activity was found in diseases characterised by excessive bone loss and formed the basis of new therapeutic options. In several studies, a human monoclonal antibody to RANKL (denosumab) was investigated for the treatment of bone diseases. Denosumab is a promising therapeutic option due to its bone-protective effects.

Weight gain and recurrence in idiopathic intracranial hypertension: a case-control study.

OBJECTIVE: To determine whether weight gain is associated with recurrence in idiopathic intracranial hypertension (IIH). METHODS: Medical records of adult patients with IIH seen between 1993 and 2009 at 2 university hospitals were reviewed to identify those with and without recurrence. Patients with documented height and weight at presentation and at subsequent visits were studied. The Wilcoxon rank sum test was used to compare mean body mass index (BMI) and percent weight change between the groups of patients with recurrence and without recurrence. The signed-rank test was used for comparing BMI within groups at the various time points. RESULTS: Fifty women with IIH were included in the analyses: 26 had IIH recurrence and 24 did not. Patients with recurrence had greater BMI at the time of recurrence compared to BMI at diagnosis (p = 0.02, signed-rank test). They also demonstrated a greater degree of weight gain between initial resolution and recurrence (BMI change +2.0 kg/m(2) [-1.5 to 10.8]) compared to patients without recurrence (-0.75 kg/m(2) [-35 to 3.6], p = 0.0009, Wilcoxon rank sum test). Patients without recurrence demonstrated stable weights (0%[95% CI -9.6 to 10.1%]), while patients with recurrence demonstrated a 6% weight gain ([-3.5 to 40.2%], p = 0.005), with an average rate of BMI gain of 1.3 kg/m(2)/year vs -0.96 kg/m(2)/year in those without recurrence. CONCLUSION: Patients with IIH recurrence had significant increases in BMI compared to patients without recurrence in this cohort. Patients with resolved IIH should be advised that weight gain may be a risk factor for IIH recurrence.

The effects of feeding history and environment on condition, body composition and growth of bluegills Lepomis macrochirus.

Initial relative mass (W(R), low v. high) and energetic trajectory in time (starved v. fed) were experimentally manipulated in bluegill Lepomis macrochirus. Fed fish starting at low W(R) grew more and gained more W(R) than fed fish starting at high W(R). Similarly, starved fish starting at high W(R) lost more mass and W(R) than did starved fish starting at low W(R). Temporal changes in other variables did not consistently match that of W(R), but, by the end of the experiment, proximate composition showed a high correlation to W(R). Regression slopes of W(R) on proximate composition increased with time in the laboratory. Differences between wild and laboratory fish appeared to result from relaxation of environmental stress. When excess resources are available such that L. macrochirus grow, condition indices will increase, but individual response will depend on initial values and thus past environmental experience.

Intramedullary spinal sarcoidosis: clinical improvement reflected in T-lymphocyte subpopulation ratios.

STUDY DESIGN: Case report. OBJECTIVES: A case report of spinal sarcoidosis improving clinically and radiographically with treatment which correlated with improvement in cerebrospinal fluid T-lymphocyte subpopulation ratios. SETTING: Walter Reed Army Medical Center. CASE REPORT: A 46-year-old man presented with an enhancing spinal cord lesion. Lymph node biopsy confirmed sarcoidosis, and cerebrospinal fluid (CSF) analysis showed elevation in the ratio of two T-lymphocyte subpopulations. Treatment with steroids resulted in clinical resolution and immunocytologic improvement in the CSF.

Thrombotic thrombocytopenic purpura-induced posterior leukoencephalopathy in a patient without significant renal or hypertensive complications.

A 40-year-old male with recent-onset idiopathic thrombotic thrombocytopenic purpura (TTP) developed focal transient neurological findings lasting for several hours, remitting, then recurring in a different pattern. Brain magnetic resonance imaging (MRI) was consistent with a posterior leukoencephalopathy and electroencephalography demonstrated lateralized slowing during an episode. No acute ischemic changes were found on diffusion-weighted imaging. Close monitoring in an intensive care setting revealed no significant hypertensive episodes. The patient's condition resolved with plasmapheresis and immunoglobulin therapy. The relation of TTP to reversible posterior leukoencephalopathy syndromes is discussed. Clinical features of this case suggest a mechanism for TTP-induced leukoencephalopathy independent of hypertension and renal failure.

Management of spontaneous pneumothorax during pregnancy: case report and review of the literature.

Spontaneous pneumothorax rarely occurs during pregnancy. Only 22 nonmalignancy-related cases have been previously published. Herein we report a case of recurrent spontaneous pneumothorax during the third trimester of pregnancy that necessitated surgical intervention. At thoracotomy, a large bulla was excised from the lower lobe of the right lung; abrasive pleurodesis was subsequently done. Postoperatively, the patient had regular contractions, which were successfully stopped with intravenous administration of magnesium sulfate. Indications, procedures, and pre-cautions for operative intervention during pregnancy are discussed.

Preterm labor and congenital candidiasis. A case report.

Intrauterine infection with Candida is a rare complication of pregnancy. We report a case of preterm labor associated with Candida chorioamnionitis and the subsequent delivery of an infant with congenital Candida infection. We also discuss possible factors responsible for the increased invasiveness of this usually benign condition and management considerations once the diagnosis is made.

A genetic review of complete and partial hydatidiform moles and nonmolar triploidy.

Complete and partial hydatidiform moles are genetically aberrant conceptuses. Usually, complete moles have 46 chromosomes (diploidy), all of paternal origin. Most partial moles have 69 chromosomes (triploidy), including 23 of maternal origin and 46 of paternal origin. Triploidy that involves 23 paternal chromosomes and 46 maternal chromosomes is not associated with molar placental changes and, rarely, can result in a live-born infant with multiple birth defects. Herein we review the mechanisms of fertilization that may produce these unbalanced sets of parental chromosomes and the role of genomic imprinting as a possible explanation for these clinical conditions.

Selective embryo reduction of an interstitial heterotopic gestation.

A case of combined interstitial and intrauterine pregnancy is described. The sonographic finding of a thick myometrial bridge separating a twin pregnancy may be unique to heterotopic cornual pregnancies and is illustrated. The method of selective embryo reduction with potassium chloride to terminate the interstitial pregnancy without damage to the intrauterine pregnancy is also described. The intrauterine pregnancy continued successfully to term.

Absence of hyperinsulinemia in isoimmunized fetuses treated with intravascular transfusion.

We serially sampled blood from fetuses of five severely isoimmunized pregnancies at the time of each intrauterine intravascular transfusion and at birth. We were unable to demonstrate either an elevation in the plasma insulin/glucose ratio or a relationship between the insulin/glucose ratio and hemoglobin concentration at any time period. Plasma total glutathione concentration, however, decreased dramatically from the initial to the second transfusion (323 +/- 114 to 43 +/- 9 ng/ml; t = -5.06, p less than 0.01). We speculate that intrauterine transfusion may modify or prevent the previously reported fetal pancreatic beta-cell hyperplasia and hyperinsulinemia associated with isoimmunization by decreasing red blood cell hemolysis and thereby circulating glutathione.

Uterine incarceration during the third trimester: a rare complication of pregnancy.

Uterine incarceration that manifests during the third trimester or at term is a serious and rare complication of pregnancy. The pregnant patient may complain of low-abdominal pain, low-back pain, urinary retention, and constipation, or the patient may be asymptomatic until labor begins. The diagnosis is difficult, and physical findings can be misleading. Ultrasonography and magnetic resonance imaging can be helpful if the anteriorly displaced cervix is clearly depicted. If incarceration of the retroverted uterus persists until term, a cesarean section is necessary. Recurrent uterine incarceration has been reported; therefore, the patient should be monitored closely during subsequent pregnancies. Herein we describe three cases of uterine incarceration during the third trimester and review the literature with respect to incidence, differential diagnosis, management, and complications of this condition.

Perinatal outcome following intravascular transfusion in severely isoimmunized fetuses.

Twenty-six severely isoimmunized pregnancies managed exclusively with ultrasonographically guided intravascular fetal transfusions are reported. The mean gestational age plus and minus one standard deviation (+/- SD) was 26.3 +/- 3.6 weeks and the mean hematocrit (+/- SD) prior to initial transfusion was 20.6 +/- 6.7%. Four of seven hydropic fetuses and 9 of 19 without hydrops were less than or equal to 26 weeks gestation at the first transfusion. Overall survival was 85% (22/26). Survival was similar whether or not fetal hydrops was present (6/7 vs. 16/19) and whether or not the first transfusion was administered at less than or equal to 26 weeks gestation (10/13 vs. 12/13).

Anesthesia, cardiopulmonary bypass, and the pregnant patient.

For the perioperative management of pregnant patients with severe cardiac or aortic disease who require a cardiac surgical procedure and cardiopulmonary bypass, a close, cohesive, working relationship must exist among several medical and surgical specialties. For appropriate management, the well-being of both the mother and the fetus must be considered. The best interests of the mother and the fetus may not coincide, and optimal therapy for one may be inappropriate for the other. We present 10 cases of severe cardiac or aortic disease in pregnant women who required surgical intervention. Eight patients underwent cardiopulmonary bypass during pregnancy, and two patients had cesarean section performed immediately before cardiopulmonary bypass. We also discuss the pertinent pharmacologic aspects related to the perioperative period and the management of cardiopulmonary bypass for the pregnant patient.

Effects of intravascular, intrauterine transfusion on prenatal and postnatal hemolysis and erythropoiesis in severe fetal isoimmunization.

In an investigation of the effects of intrauterine, intravascular transfusions (IUT) on fetal and neonatal hemolysis and erythropoiesis, 12 fetuses who received IUT for treatment of severe isoimmunization had serial measurements of hemoglobin concentration, Kleihauer-Betke stains to detect fetal hemoglobin-containing erythrocytes, and determination of plasma erythropoietin (EPO) concentration before each IUT, at birth, and postnatally. Reticulocyte counts and sensitizing antibody titers were measured in five fetuses. Mean values before the first IUT, before the final IUT, and at birth were as follows: hemoglobin level, 6.1, 9.1, and 11.3 gm/dl; reticulocyte count, 22.7%, 0.5%, and 0.9%; fetal hemoglobin-containing erythrocytes, 100%, 1.6%, and 1.5%; and EPO level, 12, 56, and 756 mU/ml, respectively. Only one neonate required exchange transfusion. In the first month postnatally, all infants had a profound anemia. All but one infant required simple blood transfusions postnatally. Before the first postnatal transfusion, mean hemoglobin concentration was 6.2 gm/dl, mean reticulocyte count was 0.8%, mean erythropoietin concentration was 23 mU/ml, and the sensitizing antibody titer remained markedly elevated. Except for the surge of EPO at birth, EPO levels did not rise prenatally or postnatally unless marked anemia (hemoglobin level less than 5 gm/dl) occurred. These observations suggest that the intrauterine and postnatal anemia in fetuses who receive IUTs may be explained both by hemolysis of newly formed erythrocytes by circulating antibody, which typically persisted for more than a month after birth, and by suppressed erythropoiesis.

The prevalence of substance abuse in patients with suspected preterm labor.

Premature labor is a recognized complication of substance abuse in pregnancy. However, the prevalence of substance abuse in patients first seen with symptoms of preterm labor and who deny use of illicit drugs is unknown. Between July 1, 1988, and December 15, 1988, 141 patients first seen at Northwestern Memorial Hospital in suspected preterm labor and a comparison group of 108 uncomplicated laboring term patients had urine toxicology screening performed to detect substance abuse. Positive urine toxicology screenings were found in 24 of 141 (17.0%) patients with suspected preterm labor and in 3 of 108 (2.8%) patients in the comparison group. The most common substance identified was cocaine (14/24 and 1/3, respectively). Of those patients in suspected preterm labor, 22 of 86 (25.6%) clinic patients had positive urine toxicology screenings as did 2 of 55 (3.6%) private patients. On the basis of our observations, we recommend that patients admitted in possible preterm labor be encouraged to submit to screening for substance abuse so that appropriate counseling and prenatal and neonatal care become available for these high-risk patients.