Failure of an Irving tubal sterilization.

Failure of the Irving method of Bilateral tubal ligation is rare, as evidenced by the absence of a current previous report in the literature. The present case represents an infrequent technical failure of this established method of female sterilization. The literature and possible causes of failure are reviewed and a form of management is considered. Treatment of this patient was influenced by the presence of additional gynecologic abnormalities.

High prevalence of vitamin D insufficiency in healthy elderly people living at home in Argentina.

OBJECTIVE: To evaluate the nutritional status of vitamin D in urban populations of healthy elderly people living at home, in different regions of Argentina. DESIGN: Cross-sectional study. SUBJECTS: In total, 386 ambulatory subjects over 65 y of age from seven cities (between latitude 26 degrees S and 55 degrees S) were asked to participate between the end of winter and the beginning of spring. Of these, 369 accepted, 30 were excluded because of medical history or abnormal biochemical determinations. Finally, 339 subjects (226 women and 113 men) (X+/-s.d.) (71.3+/- 5.2 y) were included. RESULTS: Serum 25OHD levels were lowest in the South (latitude range: 41 degrees S-55 degrees S): 14.2+/-5.6 ng/ml (P<0.0001vs North and Mid regions); highest in the North (26 degrees S-27 degrees S): 20.7+/-7.4 ng/ml (P<0.03 vs Mid, P<0.0001vs South); and intermediate in the Mid region (33 degrees S-34 degrees S) 17.9+/-8.2 ng/ml. Serum mid-molecule PTH (mmPTH) and 25OHD were inversely related: (r=-0.24, P<0.001). A cutoff level of 25OHD at which serum mmPTH levels began to increase was established at 27 ng/ml. A high prevalence (87-52%) of subjects with 25OHD levels in the deficiency-insufficiency range (25OHD levels <20 ng/ml) was detected. CONCLUSION: This study shows that vitamin D deficiency/insufficiency in the elderly is a worldwide problem. Correction of this deficit would have a positive impact on bone health of elderly people.

The military gynecologist in low-intensity conflict environment.

U.S. military medical personnel have been assigned to Honduras since August 1983. While reserve components have 2-week assignments and Air Force medics receive 3-month assignments, U.S. Army medical personnel are assigned for 6-month tours. Duties include rendering medical care and air evacuation capability to all U.S. Forces in the Central American area of operations, conducting medical civic action programs termed MEDRETES, and assisting the host government in developing and conducting a health care system for indigent rural Hondurans. Gynecological care to women soldiers assigned to this low-intensity conflict environment and gynecological surgery capability for indigent Hondurans has been one important aspect of the military medical presence.

Gynecologic evaluation of the first female soldiers enrolled in the Gulf War Comprehensive Clinical Evaluation Program at Tripler Army Medical Center.

Tripler Army Medical Center initiated the Department of Defense's Persian Gulf Illness Comprehensive Clinical Evaluation Program (CCEP) on June 15, 1994. In the first 5 months, 100 patients enrolled in this program. Sixteen (16%) were women who served in the Persian Gulf during Desert Shield/ Desert Storm, and 1 (1%) was the dependent wife of a Gulf War veteran who is experiencing illness that may be related to the Persian Gulf War. All 17 women enrolled in the CCEP were evaluated in the Tripler Army Medical Center Obstetrics and Gynecology Clinic between June 17 and November 10, 1994. Each patient underwent gynecologic history, pelvic exam, Pap smear, and screen for fecal occult blood. Ten patients underwent baseline mammograms and 13 patients underwent urogenital and cervical cultures for aerobic bacteria, chlamydia and herpes simplex. The 1 patient with an abnormal Pap smear underwent cervical and endocervical biopsies and colposcopy (histology demonstrated no dysplasia or neoplasia). Half of the 16 Gulf War veterans experienced gynecologic problems while serving in the Gulf and 43% admitted gynecologic problems since returning in 1991. Of 6 patients who became pregnant after returning, 5 had normal pregnancies and 1 suffered four miscarriages.

The medical care system and medical readiness training exercises (MEDRETEs) in Honduras.

Honduras is the second largest and one of the least urbanized of the six Central American countries. Beginning with Big Pine II Military maneuvers in August 1983, U.S. military medical personnel based in Palmerola, Honduras, have been involved with a civic action-type training activity termed the Medical Readiness Training Exercise (MEDRETE). Medical officer and enlisted medics from the three services have had the opportunity to receive military medicine training in a Third World environment. The planning, preparation, and initiation of these training missions and the benefits to the participants and recipients are discussed.

Uterine scar separation in patients undergoing trial of labor (TOL) in one army hospital.

Before the mid-1980s, repeat cesarean section was the usual method of delivering all patients who had a previous cesarean section. With cesarean section rates exceeding 20% in the 1980s, a concerted effort to reduce this high rate was formulated in all military teaching hospitals. One proposed method to decrease the overall cesarean section rate was to reduce the number of repeat cesarean sections. Trial of labor (TOL) with vaginal birth after cesarean section was one method of decreasing the high cesarean section rate. Although vaginal birth after cesarean section has a relatively high success rate and has been shown to be safe for mother and infant, TOL is not risk free. One of the potential complications of TOL is uterine scar separation, which may lead to perinatal mortality. This report discusses uterine scar separation during TOL during a 1-year period at one medium-size U.S. Army teaching hospital.

Laparoscopically assisted vaginal hysterectomy in an Army medical center.

Over the past 5 years, laparoscopic assisted vaginal hysterectomy (LAVH) has progressed from an experimental procedure to an alternative operation when abdominal hysterectomy is indicated. During a 15-month period, 31 patients underwent LAVH at Tripler Army Medical Center for treatment of gynecologic conditions that traditionally required abdominal hysterectomy. The benefits of the procedure and the complications encountered during surgery are discussed. A comparison of our data with data presented in other reports in the literature is considered favorable. While the complication rate was 16%, there was no mortality or serious morbidity. With experience and proper training of gynecologic surgeons, LAVH is an alternative to abdominal hysterectomy in selected cases.

Genital mutilation of young girls traditionally practiced in militarily significant regions of the world.

Very few physicians practicing in the United States have experience in treating female patients who have undergone mutilation of the external genitalia, incorrectly termed female circumcision. This procedure, known as infibulation, consists of removing the clitoris, prepuce, and portions of the labia of young girls, usually younger than 7 years of age. Infibulation has been practiced by lay midwives for centuries in the Horn of Africa and in other African and Middle Eastern countries. This paper discusses infibulation, the techniques, and the recommended medical and obstetric management of patients subjected to genital mutilation. With increased immigration to the United States by Africans and Middle Easterners, and with readily increasing military medical deployments, primary care physicians and specialists can expect to be confronted with patients who have undergone this disfiguring procedure during their youth.

Tuberculous peritonitis in a young female diagnosed using mini-laparotomy: a case report.

An 18-year-old female Pacific Islander with abdominal pain, ascites, and fever was transferred to our hospital with suspected ovarian malignancy. These nonspecific clinical features of tuberculous peritonitis in a female frequently contribute to misdiagnosis. Preoperative findings included negative sputums, negative purified protein derivative, and no acid-fast bacilli (AFB) found in peritoneal fluid or fine needle biopsy of the omentum. Tuberculous peritonitis was diagnosed after omental biopsy obtained at mini-laparotomy showed granulomatous inflammation and positive isolation of AFB.

Appendectomy during pregnancy: a survey of two army medical activities.

Acute appendicitis is the most common nonobstetrical surgical condition of the abdomen complicating pregnancy. Appendectomy reportedly is performed during pregnancy once for every 1,500 deliveries. Although the incidence of appendicitis occurring in pregnant women is considered to be the same as in nonpregnant women, the signs and symptoms, and the laboratory findings usually associated with appendicitis in the nonpregnant condition, are frequently unreliable during pregnancy. Using the Computer Diagnostic Data System, we completed a retrospective analysis on all appendectomies performed at two Army Medical Activities (MEDDACs) during a 2-year period. With a representative large Army MEDDAC and a representative medium-sized Army MEDDAC studied, the incidence of appendectomy during pregnancy was the same frequency as in previous reports. The only consistent finding in all pregnant patients who underwent appendectomy was right lower quadrant abdominal pain. Presenting signs and symptoms, clinical evaluations, laboratory findings, and surgical management is discussed. No morbidity or mortality occurred during this study.

Fine needle aspiration of palpable breast masses performed in a military obstetrics/gynecology clinic: a follow-up report.

Evaluation of breast disease has increasingly become more integrated into the routine gynecology care of women seen in the obstetrics/gynecology (OB/GYN) clinic. Patients expect their obstetrician-gynecologist to have expertise in evaluation and diagnosis of breast problems that arise from self examination, routine mammography, unusual breast symptoms, or clinical findings during annual gynecology examinations. In 1993, Tripler Army Medical Center Department of Obstetrics and Gynecology initiated a Breast Evaluation Clinic to better serve its patients with breast problems and to train military OB/GYN resident physicians in evaluation and diagnosis of breast disease. A preliminary report of the first 40 patients evaluated in this Breast Evaluation Clinic was previously published in Military Medicine. The patient evaluation, the technique of performing fine needle aspiration (FNA) of breast masses, and the cytologic slide preparation was described in the preliminary report. This follow-up report presents a total of 245 patients who underwent FNA of palpable breast masses in the Tripler Army Medical Center OB/GYN Department Breast Evaluation Clinic between December 1, 1993, and December 8, 1995. Patients found to have suspicious breast masses or abnormal mammography reports at the time of evaluation were immediately referred to the Department of General Surgery for evaluation rather than be subjected to FNA in the OB/GYN Department Breast Evaluation Clinic. Of the 245 patients who underwent FNA, 26 (11%) were referred to the Department of General Surgery for treatment or open biopsy based on cytologic diagnosis and evaluation in the OB/GYN Breast Evaluation Clinic. No major complications from the FNA procedures occurred during this 2-year study period.

Fine needle aspiration of palpable breast masses with immediate cytologic interpretation in an OB/GYN residency training program: a preliminary report.

Increasing emphasis has been placed on the training of obstetrics and gynecology residents in the evaluation of patients with breast disease. In the past, one had to refer to the surgery, radiology, or pathology literature to obtain current information on fine needle aspiration. With the present mandate to include breast disease in the academic curricula of obstetrics and gynecology residency training, the Department of Obstetrics and Gynecology, Tripler Army Medical Center, initiated training in breast evaluation. This preliminary report describes the Tripler Obstetrics and Gynecology Department Breast Evaluation Clinic and presents the findings of the first 40 patients.

Development of a core curriculum in professional growth: practice management military model.

Military medicine has faced some big challenges in recent years. Military treatment facilities have not been exempt from these alterations, as the American public has sought to reinvent government practices with regard to medicine. Until recently, professional education consisted almost entirely of emphasis in the particular content of the chosen field. Obstetrics and gynecology was one of the first medical specialties to recognize the importance of practice management, professional growth and development, and to require exposure to it as part of the residency process. The Department of Obstetrics and Gynecology's instructional objectives dealing with professional growth and development originated as part of the military-unique curriculum for physicians implemented at Tripler Army Medical Center in Hawaii. Later, these objectives were used at Madigan Army Medical Center in Tacoma, Washington. Recent changes in the health care environment, coupled with an increasing awareness of professional liability and the newer specter of managed care, force physicians to learn the cost of each health encounter and to be more familiar with the business aspects of health care. As medicine in general is changing, the curricula have been revised and tailored to the needs of our physicians with the addition of ethics, managed care, utilization, and practice management.

Uterine packing in the combined management of obstetrical hemorrhage.

Uterine packing to control obstetrical hemorrhage has been generally discouraged over the past several decades. Intractable uterine hemorrhage postpartum or following an abortion is an extremely vexing management problem for the physician and continues to be a leading cause of maternal mortality. Uterine packing should be considered as a presurgical management tool after lacerations of the lower genital tract, uterine rupture, or retained products have been ruled out and when conventional therapy fails to control uterine hemorrhage. We describe two obstetrical patients with intractable uterine hemorrhage who were managed with uterine packing in combination with other methods of therapy. Causes of obstetrical hemorrhage and techniques of packing the uterus are discussed.

Myomectomy during early pregnancy.

Abdominal pain during early pregnancy may be caused by leiomyoma of the uterus. Inconsistency of uterine size and gestational dates in a pregnant patient with acute abdominal pain may be the first sign of leiomyoma. This 31-year-old primigravida presented with progressively worsening lower abdominal pain at 12 weeks gestational age. Ultrasonography and magnetic resonance imaging demonstrated a large fundal heterogeneous mass and an intrauterine gestation compatible with her menstrual dates. Exploratory surgery and myomectomy confirmed a large leiomyoma showing benign degenerative changes. The operative procedure was successful, and the pregnancy progressed normally. An elective cesarean section was performed at 37 weeks gestation after confirming fetal maturity by amniocentesis and serial ultrasonography. Abdominal pain in a pregnant patient with leiomyoma uteri may be attributable to degenerative changes in the myoma. Surgical intervention during pregnancy is occasionally necessary in uncommon cases of intractable pain.

Excision of urethral diverticulum calculi in a pregnant patient on an outpatient basis.

Although the incidence of urethral diverticula in women of reproductive age ranges from 0.6% to 6%, urethral diverticulum calculi are rarely reported. This report describes excision and outpatient management of urethral diverticulum calculi in a symptomatic pregnant patient. The etiology, diagnosis, and recommended therapy of urethral diverticulum calculi are discussed. Historically, surgical therapy has been considered appropriate; however, recent technologic advancements--including ultrasound and lithotripsy--may change this widely accepted method of treatment.

Recurrent cornual ectopic pregnancy in a patient with leiomyomata uteri.

The present report describes a rare finding of recurrent cornual ectopic pregnancy in a patient with leiomyomata uteri. Types, incidence, and causes of ectopic pregnancy and complications of pregnancy related to leiomyomata uteri are discussed. The association of recurrent cornual ectopic pregnancy with leiomyomata uteri previously has not been reported.

Conjoined twins: report of a case and review of the literature.

Conjoined twins, known to the layperson as Siamese twins, are a rare and catastrophic obstetric event. With the approximate incidence being 1 in 50,000 births, few physicians practicing obstetrics will have the unfortunate occasion to manage this biologic anomaly. Should this event occur, early diagnosis, close prenatal management, and the proper route of delivery will assure the best possible outcome for mother and both babies. The author describes the anatomic types of conjoined twins, the prenatal diagnosis and management, the route of delivery, and the overall statistical expectation. Under the best of circumstances, a good outcome is rarely achieved, but the obstetric goal should be a healthy mother and two salvageable babies.