Cavum veli interpositi cyst: prenatal diagnosis and postnatal outcome.

OBJECTIVE: The cavum veli interpositi (CVI) is a space within the double-layered tela choroidea of the third ventricle. Occasionally, this space is fluid-filled and sonographically visible as an interhemispheric anechoic cyst. Because of its rarity, the incidence of CVI cyst is undetermined and the outcome of affected individuals has been found to be variable. The aim of this study was to report our experience of the sonographic findings and outcome of fetuses affected by CVI cysts. METHODS: In five fetuses with a CVI cyst, we performed targeted prenatal ultrasound scans of intracranial structures and a detailed anatomical survey to rule out associated malformations. Follow-up consisted of neurological examination and neurosonography. RESULTS: The CVI cyst appeared as a well-defined anechoic lesion without adjacent mass effect. In all fetuses the cyst was single and in two cases it enlarged slightly during pregnancy. The cyst was isolated in three fetuses and associated with borderline ventriculomegaly in two. A single umbilical artery was the only associated extracranial anomaly and this was detected in only one fetus. Neurosonography confirmed the presence of CVI cysts in all cases after delivery. During postnatal follow-up (range 10-48 months), the cyst regressed in one case within 1 month after delivery while the size of the others remained stable. No infant developed psychomotor disorders. CONCLUSIONS: Prenatal sonographic diagnosis of CVI cysts is feasible. Its finding in isolation is consistent with favorable postnatal outcome.

Twin-twin transfusion syndrome.

Twin-twin transfusion syndrome (TTTS) is a condition unique to monochorionic pregnancies, although very few case reports described the syndrome in dichorionic placentas. The aetiology of TTTS relies in the presence of at least 1 arterio-venous placental anastomosis, through which unequal blood exchange from one twin (donor) to the co-twin (recipient) occurs. The diagnosis of TTTS relies on the sonographic detection of oligohydramnios in the donor's sac and polyhydramnios in the recipient's sac in the second trimester, although signs of TTTS are present since the first trimester. Treatment options for TTTS include serial amnioreduction, septostomy, selective feticide of the apparently sick twin, and selective photocoagulation of placental vessels (SLPCV). Because of the growing evidence that SLPCV is the most efficacious therapy compared to amnioreduction with/without septostomy, the authors reviewed in details the effects of SLPCV on fetal growth and circulation. The authors further explore literature with regard to the prognostic factors. Finally, because Quintero staging system is actually under debate, they discuss the most recent findings on this topic and propose a new staging system to assess severity of TTTS at presentation (Rossi staging system). New topics for future research, which would probably further clarify the natural history of TTTS, are also proposed.

[Sonoembryological criteria in the evaluation of gestational age]. / Utilizzo di criteri sonoembriologici nella valutazione dell'età gestazionale.

AIM: The progressive appearance of specific embryological structures has been successfully used to define the ultrasonographic gestational age (GA). In our study we have revised this technique by comparing our results with the ones from Warren et al. obtained in 1989. Aim of the study is to evaluate the accuracy of this technique when applied working with new instrumentations and average skilled sonographers. METHODS: Sixty-five pregnant women with correct GA ranging between 4 and 12 weeks have been observed between April 2003 and March 2004. We exposed them to an ultrasound examination looking for these structures in terms of presence/absence: gestational sac, yolk sac, embryo pole with cardiac activity, thromboencephalic cavity, falx cerebri and physiologic midgut herniation. We used transvaginal sonography (TVS) until 11 weeks of GA, from 11 weeks + 1 day we switched to transabdominal sonography (TAS). We have compared our results with the ones published by Warren et al. RESULTS: Gestational sac's visualization has been possible between 4 weeks+3 days/5 weeks of GA. Yolk sac has been visualized between 5 weeks+4 days/6 weeks of GA, embryo with cardiac activity has been observed between 5 weeks+6 days/6 weeks+2 days of GA, romboencephalic cavity has been visualized between 7 weeks and 7 weeks+5 days, falx cerebri has been detected between 9 weeks+1 day/10 weeks+3 days. Visualization of physiologic midgut herniation has been possible between 8 weeks+3 days/8 weeks+6 days; it disappeared between 10 weeks+3 days/11 weeks +1 day. CONCLUSIONS: Although the technological improvement in the US equipment in the last 15 years and the combination of TVS with TAS, there has been no advanced visualization of those single embryological structures. Indeed there has been a reduction of the time range during which those structures have been visualized. This improvement might have important practical implications in the ultrasonographic assessment of GA.

Comparison of Diane 35 and Diane 35 plus finasteride in the treatment of hirsutism.

OBJECTIVE: To compare the clinical efficacy of an original combined therapy with cyproterone acetate, 2 mg, and ethinylestradiol, 35 microgram (Diane 35), plus finasteride (5 mg) for 2 weeks per month with that of Diane 35 alone in hirsute women. DESIGN: Prospective randomized, single-blinded study. SETTING: Outpatients in an academic research environment. PATIENT(S): Fifty women with idiopathic hirsutism (IH) or the polycystic ovary syndrome (PCOS). INTERVENTION(S): Group 1 (n = 25) received Diane 35 alone and group 2 (n = 25) received Diane 35 plus finasteride. The latter drug was administered using a new therapeutic scheme: 14 consecutive days for each therapeutic cycle. MAIN OUTCOME MEASURE(S): Hormonal evaluation was done before beginning treatment and after 3 and 6 months of therapy. Hirsutism was graded at 3-month intervals. RESULT(S): The combination of Diane 35 plus finasteride for 14 days significantly decreased the hirsutism score after 3 months of therapy, while Diane 35 alone induced this effect after 6 months. CONCLUSION(S): Finasteride in combination with Diane 35 for 14 days is effective, well accepted, and safe in hirsute patients, as the amount of antiandrogenic drugs administered is much lower than that in conventional treatment.

Reducing the inappropriate use of parenteral nutrition in an acute care teaching hospital.

BACKGROUND: Parenteral nutrition (PN) is a form of nutrition that can be life-saving, but its use has inherent risks and it is expensive. Nutrition support teams have been shown to reduce both the rate of complications and excessive use of PN. METHODS: Criteria were established to evaluate the appropriateness of PN use in a 487-bed community teaching hospital. A prospective study of 50 consecutive patients, who received either central or peripheral PN, was conducted. RESULTS: The 50 patients received 469 days of PN. We found that 233 (49.7%) of the 469 days of PN were avoidable. This resulted in the creation of a formal approval process that required prior approval by a physician-directed multidisciplinary advisory committee before PN could be instituted. The amount of PN subsequently decreased from 500 patient days of PN per month to less than 100. CONCLUSIONS: This study supports the idea that inappropriate use of PN can be reduced by physician education plus the continuing oversight of a physician-directed multidisciplinary advisory group.

Umbilical cord morphology and pregnancy outcome.

Traditionally, the prenatal assessment of the umbilical cord (UC) is limited to the assessment of the number of vessels and to the evaluation of umbilical artery blood flow parameters. Morphologic aspects of the UC have usually been studies by pathologists and retrospectively correlated with the perinatal outcome. The introduction of more sophisticated imaging techniques have offered the possibility to investigate the UC characteristics during fetal life from early to late gestation. A number of investigations have demonstrated that an altered structure of the UC can be associated with pathologic conditions (i.e. Preeclampsia, fetal growth restriction, diabetes, fetal demise). Nomograms of the various UC components have been generated and allow the identification of lean or large umbilical cords, entities frequently associated with fetal growth abnormalities and diabetes. A Wharton's jelly reduction has also been invoked as a possible cause of fetal death in the presence of single umbilical artery. Prenatal morphometric UC characteristics as well as arterial and venous blood flow parameters in normal and pathologic conditions will be discussed.

Leuprolide acetate as a salvage-therapy in relapsed epithelial ovarian cancer.

A large number of studies have been conducted in patients affected by epithelial ovarian cancer to assess the potential utility of a variety of different regimens in patients who have relapsed after primary surgery and adjuvant chemotherapy. In this open prospective study, 32 patients with ovarian cancer of epithelial histology who had relapsed after platinum-based line chemotherapy and had exhausted all standard treatments, received Leuprolide acetate depot 3.75 mg, intramuscularly once a month until tumor progression. Four patients (12.5%) had clinical and/or radiological partial response; remission was then maintained for a mean duration of 8.7 months (range 6-11 months) before new progression occurred. Five patients (15.6%) remained stable for a mean time of 5.2 months (range 4-6 months) and 23 patients (71.9%) continued to progress following therapy and have since died by tumor with a median survival of 3.6 months after initiation of the protocol. Treatment is well-tolerated and no toxicity has been noted. These data stress the significant activity of Leuprolide acetate as a salvage therapy in patients with relapsed advanced epithelial ovarian cancer after previous platinum-based chemotherapies.

[Kerion of the vulva. Report of a case and review of the literature]. / Kerion a localizzazione vulvare. Descrizione di un caso e revisione della letteratura.

We report a case of a 43 year old woman who developed an extensive vulvar kerion caused by Trichophyton menthagrophytes that was initially mistaken for a bacterial infection. The peculiarity of this case lies in the fact that the kerion is rarely located in the vulva and it has not yet been described in the literature. On the contrary, cases have been found in the scalp, beard, eye-brow, etc. We discuss the etiopathogenetic aspects, criteria for differential diagnosis and therapy management of this rare clinical picture.

Neuroimaging of ventriculomegaly in the fetal period.

Fetal cerebral ventriculomegaly (VM) is defined as an enlargement of the lateral ventricles of the developing fetal brain. It is diagnosed when the width of one or both lateral ventricles, measured at the level of the atrium, is ≥10 mm. VM is defined as mild when the atrial width is 10-15 mm and severe when >15 mm. VM is a non-specific sonographic sign which is common to various pathological conditions. It is frequently associated with neural and extraneural anomalies. The rate of associated malformations is higher (≥60%) in severe VM and lower (about 40%) in cases of mild VM. When an abnormality is associated with severe VM the incidence of aneuploidies is high (>15%); in isolated mild VM the mean value of aneuploidy is 2.7%. The rate of infections in severe VM is 10-20%, in mild forms 1-5%. Since the prognosis in cases of VM depends mainly on the associated anomalies, a careful examination of the fetus, particularly of the brain, is mandatory. Magnetic resonance imaging can be a useful diagnostic tool complementary to ultrasound in order to recognize subtle brain anomalies, such as neuronal migration and proliferation disorders.

Gastrointestinal stromal tumors mimicking gynecological masses on ultrasound: a report of two cases.

Gastrointestinal stromal tumors (GISTs) are among the most common mesenchymal tumors of the gastrointestinal tract. Diagnosis of GIST on ultrasound examination can be difficult because of their similarity in appearance to gynecological neoplasms. We present two cases of GIST originating from the small bowel and the stomach, which were preoperatively misdiagnosed as a uterine leiomyoma and an ovarian tumor, respectively. The ultrasonographic differential diagnosis of these pelvic masses is discussed.

Management of a fetus affected by a genitourinary tract anomaly (excluding obstructive uropathies).

The author's personal series of 23 cases of genitourinary tract anomalies is presented. The management of each lesion is briefly discussed. The importance of recognizing uniformly fatal lesions and allowing termination (or at least avoiding an unnecessary cesarean section) is stressed. Most lesions of the genital tract can safely await delivery before any intervention is required.

How case management can improve the quality of patient care.

In January 1993, The New York Hospital Medical Center of Queens, a 487 bed acute care teaching hospital, created a Case Management Department to provide quality health care for patients that was cost efficient and at the same time reduce length of stay. Registered nurses with extensive medical and surgical expertise who were quality assurance/utilization coordinators and discharge planning nurses were cross-educated to become patient case managers. The case manager coordinates patients care services to improve the quality of the total patient experience. Reviews are conducted daily. The case managers indicate quality issues on their computer worksheets. Quality concerns are addressed and referrals made to the QA Department. Case Management Team rounds are conducted on the patient unit to discuss quality issues and barriers to discharge. Many delays were noted in patient care services i.e. Physical Therapy (P.T.) and Radiology. Readmissions within 48 hours of discharge were noted and reviewed as an indicator to monitor outcome and quality concerns. Continuous Quality Improvement (CQI) projects were initiated to reduce patient care delays. Multidisciplinary teams were formed to expedite solutions. The number of P.T. and Radiology delays were dramatically reduced through the CQI process. The case manager's role is vital to the delivery of quality patient care and containment of ever spiraling health care costs.

A multidisciplinary QA program for enteral nutrition in high-risk patients.

An increase in elderly patients and severity of illness rates means greater use of nasogastric feeding tubes for both high-risk acutely ill and chronically ill patients. When the QA screening process at Booth Memorial Medical Center revealed a certain percentage of complications with small bore, weight-tipped feeding tubes inserted through the nares, a multidisciplinary peer review committee (MPRC) was formed to review the enteral nutrition program. After a literature review to determine possible complications, the MPRC identified lung perforations due to tube misplacement, tube feeding aspiration into the lungs leading to possible aspiration pneumonia, and an internal tip separation from the tube product failure. Unconscious incubated patients on ventilators were shown as at high risk for feeding tube misplacement in an initial MPRC patient study. A second study evaluated several different feeding tube products in the medical, respiratory and surgical ICU. The MPRC established a credentialing process for physician assistants, interns and residents in feeding tube placement. The MPRC proceedings were presented to the hospital-wide QA committee for review, endorsement and recommendations on all policy and procedure changes. The conclusions were that a more concerted effort must be made to improve medical management and encourage ongoing education in the administration of enteral feedings to high-risk patients.