Successful management of extremely high-output refractory congenital chylothorax with chemical pleurodesis using 4% povidone-iodine and propranolol: a case report.

First-line therapy for congenital chylothorax is conservative treatment. However, surgical intervention or chemical pleurodesis is required for refractory cases. With all the concerns regarding its complications, povidone-iodin provided a successful management for a high-output congenital chylothorax. However, renal and thyroid function must be monitored during treatment.

Gestational Diabetes: Diagnosis, Classification, and Clinical Care.

Gestational diabetes mellitus (GDM) affects approximately 6% of pregnant women, and prevalence is increasing in parallel with the obesity epidemic. Protocols for screening/diagnosing GDM are controversial with several guidelines available. Treatment of GDM results in a reduction in the incidence of preeclampsia, shoulder dystocia, and macrosomia. If diet and lifestyle changes do not result in target glucose levels, then treatment with metformin, glyburide, or insulin should begin. It is generally recommended that pregnancies complicated by GDM do not go beyond term. For women identified to have prediabetes, intensive lifestyle intervention and metformin have been shown to prevent or delay progression to type 2 diabetes.

Women's Health Care Teams and the Future of Obstetrics and Gynecology.

Health care delivery is in a stage of transformation and a meaningful change in provision of care must also be accompanied by changes in the educational process of health care professionals. This article lays out a roadmap to better prepare obstetrician-gynecologists (ob-gyns) to succeed in interdisciplinary women's health care teams. Just as our current educational programs emphasize the development of competent surgical skills, our future programs must encourage and support the development of communication, teamwork, and leadership skills for ob-gyns. Formal integration of these fundamentals at all levels of the health care training continuum will create an educational system designed to equip all practitioners with a basic level of knowledge and provide opportunities to acquire additional knowledge and skills as needs and interest dictate. Integral to the implementation will be the evaluation of the effects of the contributions of interprofessional education on patient, practice, and health system outcomes. Successful demonstration of value will lead to the sustainability of the educational programs through recognition by physicians, health care teams, academia, health care systems, and payers.

Successful pregnancy after fertility-sparing local resection and uterine reconstruction for low-grade endometrial stromal sarcoma.

BACKGROUND: Fertility-sparing management of endometrial stromal sarcoma has been demonstrated, but reports of pregnancy after such management are rare in our current body of literature. CASE: A 16-year-old nulligravid adolescent girl presented with symptoms of menometrorrhagia and was found to have a 17-cm uterine mass. The patient underwent local resection of the mass with uterine reconstruction. Pathology revealed a low-grade endometrial stromal sarcoma. She was placed on high-dose daily megestrol acetate therapy and remained disease-free for 8 years before achieving pregnancy spontaneously. The patient underwent an uncomplicated pregnancy until 34 weeks of gestation, when she presented in preterm labor and underwent cesarean delivery of a liveborn male neonate, with no evidence of disease recurrence. CONCLUSION: Fertility-sparing management and close follow-up of low-grade endometrial stromal sarcoma may be a viable option for those desiring future fertility.

Spontaneous methicillin-resistant Staphylococcus aureus epidural abscess in pregnancy.

BACKGROUND: Epidural abscess is a rare complication of regional anesthesia, and spontaneous formation is even more uncommon. Diabetes mellitus, concomitant infection, intravenous drug use, and immune suppression are risk factors for spontaneous epidural abscess. CASE: A 29-year-old white woman presented at 28 weeks of estimated gestational age reporting an intermittent headache. She had Horner syndrome and was hospitalized. A cervicothoracic epidural abscess was diagnosed. Surgical decompression and parenteral antibiotics resulted in complete resolution of neurologic symptoms. Cultures were positive for methicillin-resistant Staphylococcus aureous. CONCLUSION: Spontaneous epidural abscess is a rare condition and diagnosis is often delayed. The finding of Horner syndrome led to imaging of the cervical spine and diagnosis of epidural abscess. Early intervention resulted in resolution of neurologic symptoms and a successful pregnancy outcome.

Spontaneous severe ovarian hyperstimulation syndrome in successive pregnancies with successful outcomes.

BACKGROUND: Ovarian hyperstimulation syndrome is a known complication of ovarian stimulation, particularly with injectable gonadotropins. Spontaneous ovarian hyperstimulation is rare and often involves a conformational change in the follicle-stimulating hormone receptor, increasing its binding with human chorionic gonadotropin or thyroid-stimulating hormone. Few data are available regarding the management or outcomes of spontaneous ovarian hyperstimulation syndrome. CASE: A 23-year-old white female without history of infertility treatment presented with ovarian hyperstimulation syndrome in two pregnancies. The patient was treated by paracentesis catheter placement and albumin replacement. She had regression of symptoms between 11 weeks and 12 weeks of gestation in both pregnancies and delivered healthy term infants. CONCLUSION: The case presented involves a patient with spontaneous severe ovarian hyperstimulation syndrome in two successive pregnancies. The patient was managed aggressively with paracentesis and albumin replacement resulting in two successful pregnancies.

Allosteric inhibition of Staphylococcus aureus D-alanine:D-alanine ligase revealed by crystallographic studies.

D-alanine:D-alanine ligase (DDl) is an essential enzyme in bacterial cell wall biosynthesis and an important target for developing new antibiotics. It catalyzes the formation of D-alanine:D-alanine dipeptide, sequentially by using one D-alanine and one ATP as substrates for the first-half reaction, and a second D-alanine substrate to complete the reaction. Some gain of function DDl mutants can use an alternate second substrate, causing resistance to vancomycin, one of the last lines of defense against life-threatening Gram-positive infections. Here, we report the crystal structure of Staphylococcus aureus DDl (StaDDl) and its cocrystal structures with 3-chloro-2,2-dimethyl-N-[4(trifluoromethyl)phenyl]propanamide (inhibitor 1) (Ki=4 microM against StaDDl) and with ADP, one of the reaction products, at resolutions of 2.0, 2.2, and 2.6 A, respectively. The overall structure of StaDDl can be divided into three distinct domains. The inhibitor binds to a hydrophobic pocket at the interface of the first and the third domain. This inhibitor-binding pocket is adjacent to the first D-alanine substrate site but does not overlap with any substrate sites. An allosteric inhibition mechanism of StaDDl by this compound was proposed. The mechanism provides the basis for developing new antibiotics targeting D-alanine:D-alanine ligase. Because this compound only interacts with residues from the first D-alanine site, inhibitors with this binding mode potentially could overcome vancomycin resistance.

Association between the use of antenatal magnesium sulfate in preterm labor and adverse health outcomes in infants.

OBJECTIVE: The purpose of this study was to determine whether the use of antenatal magnesium sulfate prevents adverse outcomes (neonatal intraventricular hemorrhage, periventricular leucomalacia, death, and cerebral palsy). STUDY DESIGN: In a controlled trial, we randomized mothers in preterm labor to magnesium sulfate, "other" tocolytic, or placebo. At delivery, umbilical cord blood was collected for the later determination of serum ionized magnesium levels. Neonatal cranial ultrasound scans were obtained periodically for the diagnosis of intraventricular hemorrhage and periventricular leucomalacia. Among survivors, the diagnosis of cerebral palsy was made at age 18 months. RESULTS: Children with adverse outcomes had higher umbilical cord magnesium levels at delivery. In regression models that controlled for confounders, which included very low birth weight, magnesium remained a significant risk factor (adjusted odds ratio, 3.7; 95% CI, 1.1-11.9; P =.03). CONCLUSION: Contrary to original hypotheses, this randomized trial found that the use of antenatal magnesium sulfate was associated with worse, not better, perinatal outcome in a dose-response fashion.