Adverse obstetrical outcomes after treatment of precancerous cervical lesions: a Belgian multicentre study.

OBJECTIVE: To assess the impact of cervical intraepithelial neoplasia (CIN) treatment on the risk of (spontaneous) preterm delivery (PD) and small for gestational age (SGA) at birth. DESIGN: A multicentre cohort study. SETTING: Maternity wards of four academic hospitals in Belgium. POPULATION: Ninety-seven exposed pregnant women (with a CIN treatment history) and 194 nonexposed pregnant women (without a history of CIN treatment). METHODS: A questionnaire and check of obstetrical files included socio-demographic characteristics, risk factors for PD, obstetrical history for all women and characteristics of the CIN treatment for exposed women. Pregnancy outcomes were recorded after delivery. The influence of previous treatment of CIN on pregnancy outcomes, adjusted for confounding variables, was assessed by Cox regression and lifetables (for the outcome gestational age at birth) and by logistic regression (for the outcomes PD and SGA at birth). MAIN OUTCOME MEASURES: Occurrence of PD and SGA at birth. RESULTS: Seventy-nine per cent of the women in the database were multiparous; 16.3% of women with a previous excisional treatment spontaneously delivered preterm, compared with 8.1% of unexposed women [odds ratio (OR), 2.19; 95% confidence interval (CI), 0.97-4.99]. When adjusting for confounding factors (ethnicity, HIV status, education, age, smoking and parity), the OR for PD was 2.33 (95% CI, 0.99-5.49). Excisional treatment did not have an impact on SGA at birth (OR, 0.94; 95% CI,0.41-2.15). The depth of the cone was >10 mm in 63.5% of the documented cases. Large cones, more than 10 mm deep, were associated with a significantly increased risk of PD (adjusted OR, 4.55; 95% CI, 1.32-15.65) compared with untreated women, whereas smaller cones (≤ 10 mm) were not significantly associated with PD (OR, 2.77; 95% CI, 0.28-27.59). The associations seen for PD with respect to the cone size did not hold for SGA at birth. CONCLUSIONS: There was an increased risk of (spontaneous) PD after excision of CIN, in particular when the cone depth exceeded 10 mm.

Introduction of human papillomavirus vaccination in Belgium, Luxembourg and the Netherlands.

AIMS: To document progress with human papillomavirus (HPV) vaccine introduction in three closely related European countries, one with organized (the Netherlands) and two with opportunistic cervical cancer screening (Belgium and Luxembourg). METHODS: Experts involved in cervical cancer screening and national immunization programs from the three countries were contacted to provide information on the decision-making process concerning the introduction of HPV vaccine. Sales statistics were obtained from Intercontinental Marketing Services. RESULTS: Advisory boards in all three countries advised organized HPV vaccination of girls of 12 years with variable catch-up policies. In Belgium, the national health authority partially reimburses the HPV vaccine for girls of 12-15 years (recently extended until 18 years). In Luxembourg, 12-year-old girls are invited for free vaccination, but the HPV vaccine is also free of charge for female adolescents of 13-17 years. The number of vaccines reimbursed in Belgium in December 2007 to May 2008 corresponds with the amount required to fully vaccinate 29% of the female population aged 12-15 years. In Luxembourg, between March and November 2008, the immunization program delivered a quantity of HPV vaccines which theoretically covered 29% of females aged 12-17 years. In the Netherlands, nationwide HPV vaccination of girls of 12 years will start in September 2009. The sales of HPV vaccines (all ages combined) were by far the lowest in the Netherlands. CONCLUSION: Up to the end of 2008, HPV vaccination efforts reached less than a third of the target population in Belgium and Luxembourg. If the latest trend continues, the current policy is expected to reach to most half of the target population. Well-planned introduction of vaccination combined with an organized screening program and active surveillance are crucial for the program to achieve and monitor its desired aims. Such surveillance should include linkage between vaccination, screening and cancer registries.

Introduction of human papillomavirus (HPV) vaccination in Belgium, 2007-2008.

This paper documents the progress of human papillomavirus (HPV) vaccine introduction in Belgium. Information on vaccine use is based on sales statistics and reimbursement claims. From November 2007 to November 2008, the National Institute for Health and Disability Insurance reimbursed the HPV vaccine for girls aged between 12-15 years. In December 2008, the age limit was extended to include girls up to the age of 18. In November 2008, the total number of HPV vaccines sold exceeded 530,000 doses. The number of vaccines reimbursed in Belgium, for the period November 2007-November 2008, corresponds to the amount required to fully vaccinate 44% of all girls aged between 12-15 years. However, the trend was decreasing over the last 10 months. By the current reimbursement policy, we can expect that maximum half of the target population can be reached. In Flanders (one of the three Communities in Belgium), the intention is to start, from September 2010, with a free school-based HPV immunisation for girls in the first year of secondary school (12 years of age), complemented with vaccination by a physician of choice. This strategy ensures a higher HPV vaccine coverage which is expected to be as high as the current coverage in the hepatitis B vaccination programme (approximately 80%) offered to boys and girls in the same age group and under the same circumstances.

Transluminal removal of a giant fibrovascular polyp of the esophagus.

Giant fibrovascular polyps of the esophagus are rare benign tumors that originate at the hypopharynx or the upper third of the esophagus. Because of the indolent and benign nature they are mostly discovered when very large with symptoms like dysphagia or regurgitation of the polyp into the mouth which can cause asphyxia and dead. The removal of these polyps is obligatory. Although more than 100 cases of giant fibrovascular esophageal polyps have been described in literature so far, the approach for removal is not yet standard and needs a customized use of medical technology from different disciplines. We present the case of a 42 year old man in whom a giant polyp was removed transorally by a combination of instruments and materials from different disciplines (gastroenterological, surgical and laryngological).

Surgical resection for colon cancer: laparoscopic assisted vs. open colectomy.

BACKGROUND/AIMS: Laparoscopic surgery has been considered for more than a decade for treatment of colorectal cancer. Although its benefits in term of postoperative comfort and parietal preservation are commonly accepted, its efficiency to achieve proper oncologic resection and to prevent tumor recurrence are still debated. The purpose of this retrospective study is to compare results of a minimally invasive laparoscopic approach to these of open surgery for treatment of colorectal cancer. METHODOLOGY: From January 1st 1999 to September 30th 2004, 239 patients underwent colorectal cancer resections; 28 of these patients underwent surgery in an emergent context and were excluded from this study. Accurate follow-up was available for 165 of the 239 patients (69%). For the study, 165 patients were divided into 3 groups: 39 patients underwent a laparoscopically assisted surgery (L group), 120 patients underwent an open colectomy (O group) and 6 patients initially treated with a laparoscopic approach were converted to open colectomy (L/O group) (conversion rate: 8.8%). RESULTS: Sex ratio, mean age and A.S.A. score, as well as patients' past records were similar in the 3 groups. Histological staging was more often stages 3 and 4 in the O group (62.5%) comparing to the L group (41%) (p < 0.5). Mean operating time was slightly longerwhen a laparoscopically assisted approach was used. Overall early mortality rate of this study was 1.8%. Combined local and general overall morbidity rate was 36%. Overall incidence of anastomotic fistulae was 4% and reintervention rate during the early postoperative period was 8%. Postoperative ileus period was often longer for patients of the O group but without statistical significance. Mean duration of hospital stay was similar in the 3 groups. Data concerning surgical resection did not show any difference between groups. None of the patients experienced a metastatic skin settlement. Overall anastomotic stenosis rate was low (2%). The overall locoregional recurrence rate was 12%, without difference between the 3 groups. Forty-two percent of these recurrences were secondarily treated by curative surgery. Similar survival rates as well as oncological spreading frequencies were found. CONCLUSIONS: Results obtained when comparing minimal invasive laparoscopically assisted surgery to open procedure are similar and efficient.

Long-term results of a non-ramdomized prospective mono-centre study of 1000 laparoscopic totally extraperitoneal hernia repairs.

BACKGROUND: Information concerning short-term results for laparoscopic extraperitoneal hernia repair is available, but long-term results remain poorly documented. The purpose of this non-randomized prospective study was to evaluate recurrence and chronic pain after hernia repair over a period longer than 10 years. MATERIALS AND METHODS: From 1995 to 2004, all patients aged 30 years or more, manifesting with inguinal hernia, were included in our study. Patients aged 20 to 30 years presenting with bilateral hernia, recurrent hernia, or who were heavy workers were also included. Patients who had pelvic irradiation, strangulated hernia, prostatic cancer resection, or a contra-indication to general anaesthesia were excluded. Of 1096 hernia repairs performed, 248 patients were excluded and underwent open repair and 848 patients (77.4%) were included in our prospective study, which corresponded to 1000 laparoscopic hernia repairs. RESULTS: The sex ratio (male : female) was 5:8, and the average age was 56 years. Seven hundred and fifty-three hernias (75.3%) were first repairs, 247 (24.7%) were recurrent hernias, and 161 were bilateral hernias. There were no mortalities. The conversion rate was 1.1%, and the global postoperative morbidity rate was 10.3%. Average follow-up was 39 months in 92.2% of the patients. Hernia recurrence rate was 1.5%. Chronic pain occurred in 2.9%. During this follow-up, 22 contra-lateral hernias appeared in those patients who initially had unilateral hernia repair (3.2%). All of these contra-lateral hernias could be successfully treated using a laparoscopic total extraperitoneal approach. CONCLUSIONS: The long-term results of this study demonstrate that preperitoneal laparoscopic hernia repair is a safe technique with a very low recurrence rate and low prevalence of chronic pain.

Spontaneous rupture of the spleen in relation to a non-Hodgkin lymphoma.

A 35-year-old man was admitted for surgery with complaints of left upper abdominal quadrant pain, tachycardia and hypotension with no history of trauma. A splenomegaly had just been diagnosed one week before, during, the work up for asthenia. An immediate CT scan revealed an intraperitoneal haemorrhage with splenic rupture. During emergency laparotomy, a splenic rupture was found and a splenectomy was performed. Histopathology of the spleen confirmed the diagnosis of a non-Hodgkin lymphoma.

Isolation of genes expressed in specific tissues of Arabidopsis thaliana by differential screening of a genomic library.

The small genome size of Arabidopsis thaliana allows the isolation of genes expressed in specific tissues and under controlled conditions by the differential screening of a genomic library, as has been shown previously for yeast and Drosophila. cDNA probes, based on poly(A)+ mRNA isolated from different Arabidopsis organs, were used in colony hybridizations with 1145 randomly chosen genomic clones, representing 27,000 kb of Arabidopsis DNA. Twenty percent of the clones containing low-copy-number sequences hybridized with one or more of the cDNA probes that were synthesized from mRNA isolated from leaves, stems, seed pods, inflorescences, callus tissue, and light-grown and dark-grown plants. Comparison of the colony hybridizations led to the identification of a large variety of clones which contain differentially expressed genes. The pattern of expression was confirmed by Northern analysis. The advantage of the described method is that it yields directly genomic sequences that contain specifically expressed or induced genes. In particular, it circumvents the construction and differential screening of cDNA libraries for every tissue or environmental parameter to be analyzed.

Effect of cimetidine, ranitidine and omeprazole on postprandial gastrin and somatostatin release in conscious dogs.

During a first series of experiments, the gastrin responses to a meal were measured and compared to the responses seen after administration of cimetidine (2.5 mg/kg/h) or omeprazole (2 mg/kg). During a second series of experiments the effects of cimetidine (2.5 mg/kg/h), ranitidine (0.5 mg/kg/h) and omeprazole (2 mg/kg) on post-prandial gastrin and somatostatin release were determined in experiments during which the intragastric pH was maintained close to 6.4. During a third series of experiments, the effects of cimetidine (2.5 mg/kg/h) and omeprazole (2 mg/kg) on basal gastrin and somatostatin release were estimated. Postprandial gastrin release was increased by cimetidine and by omeprazole. When acidification of the gastric content was prevented by intragastric titration, postprandial gastrin release was increased by about 100%. No further increase was observed when the animals were concomitantly treated with cimetidine, ranitidine or omeprazole. Intragastric titration did not alter postprandial somatostatin release. Concomitant administration of H2 blockers decreased the somatostatin response to the meal, while concomitant administration of omeprazole did not alter this release. No significant changes were observed in basal gastrin or somatostatin levels after administration of cimetidine or omeprazole.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of vagotomy and atropine on plasma somatostatin response to a meal in conscious dogs.

In 4 conscious dogs with gastric fistulas the somatostatin responses to a meal were measured and compared to the responses seen after i.v. infusion of atropine sulfate (20 and 50 micrograms.kg-1.h-1) or cimetidine (8 mg.kg-1.h-1). The experiments were repeated after truncal vagotomy. The somatostatin responses to bombesin (0.5 micrograms.kg-1.h-1) were also measured before and after vagotomy. Vagotomy decreased basal and postprandial somatostatin levels and reduced the somatostatin responses to feeding during the first 30-min period following the ingestion of the meal but not during subsequent periods. Bombesin-induced somatostatin release was increased after vagotomy. Atropine decreased the somatostatin responses to the meal before and after vagotomy. Cimetidine had no significant effect. These studies suggest that, in conscious dogs, somatostatin released into the circulation is partly under vagal control and that, as for gastrin release, vagal pathways for stimulation and inhibition are present. Our studies also suggest that cholinergic mechanisms are involved in the control of postprandial somatostatin release.

Use- and frequency-dependent blockade by UL-FS 49 of the if pacemaker current in sheep cardiac Purkinje fibres.

The mechanism by which the bradycardiac agent UL-FS 49 blocks the if pacemaker current was investigated in sheep Purkinje fibres using the two microelectrode voltage-clamp technique. If was activated by 1 s pulses applied between -30 mV and -120 mV at 0.4 Hz in a modified Tyrode solution containing BaCl2 and MnCl2, and with TRIS replacing most of the Na+. UL-FS 49 caused an exponential decline of the if current amplitude during a train of pulses. Both the rate and extent of the if reduction increased with drug concentration, without there being a resting blockade. Recovery from blockade followed a single exponential time course during prolonged hyperpolarizations. The recovery rate was extremely slow and increased with more negative voltages, as did the extent of steady state recovery from blockade. A frequency-dependent reduction of the diastolic depolarization rate resulted from a use-dependent blockade of the pacemaker current.

Manipulation of tissue fatty acid profile by intravenous lipids in dogs.

This study was undertaken to determine the effects on the fatty acid (FA) composition of various dog tissues of 4 different lipid emulsions (a 100% long-chain triacylglycerol (LCT) derived from soya bean oil emulsion, a mixed 50% medium-chain triacylglycerol (MCT)/50% LCT emulsion as well as both these emulsions supplemented with 10% fish oil (FO) triacylglycerols), when daily infused over 15 days as a substantial component of total parenteral nutrition. Lipids represented 55% of the non-protein energy. Blood samples as well as biopsies from liver, muscle and adipose tissue were taken 15 days before, and again immediately after TPN. In addition, the spleen was also removed immediately after TPN. Tissue FA composition was analysed by gas liquid chromatography of each lipid component after separation by thin layer chromatography. No differences in either safety or tolerance were detected between the different TPN preparations. In particular, infusion over 2 weeks of fat emulsions containing 10% fish oil was tolerated as well as conventional LCT and MCT/LCT emulsions. Relative linoleate content of tissue triacylglycerol (TG) was markedly increased in animals that received the LCT emulsions (e.g. from 22.6 +/- 2.5% to 32.2 +/- 0.6% in the liver), this effect being markedly reduced with MCT/LCT preparations. n-3FA were slightly incorporated into liver TG (from 0.0 +/- 0.0% to 2.3 +/- 0.7% and 1.2 +/- 0.4% for eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) respectively, with LCT + FO), but remained undetectable in extrahepatic tissue TG. Of interest, medium chain FA were found in tissue TG after infusion of the mixed MCT/LCT emulsions. As expected, changes of tissue phospholipid (PL) composition involved only long-chain FA. Infusion of soya bean oil emulsion was associated with an increased content of linoleate in liver PL (from 13.6 +/- 0.4% to 17.7 +/- 0.4%), but not in other tissues. MCT/LCT did not markedly affect PL/FA pattern in any tissue. Supplementation with fish oil was associated with an efficient incorporation of n-3FA into tissue PL, particularly in the liver (from 0.4 +/- 0.1% to 2.5 +/- 0.3% for EPA and from 3.9 +/- 0.8% to 9.1 +/- 0.4% for DHA, with the LCT + FO emulsion).

Recent developments in lipid emulsions: relevance to intensive care.

For years, intravenous lipid supply has been considered as a means of providing an efficient fuel to many tissues of the body and of preventing or correcting essential fatty acid deficiency. The potential for lipid emulsions to modulate cell function via their content of specific fatty acids and of liposoluble vitamins has not received much attention yet. Soybean [long-chain triglycerides (LCT)] emulsions provide a valuable source of energy, but they are excessively rich in omega-6 essential fatty acids (FAs). Their infusion is associated with an accumulation of linoleate and a reduction of long-chain (> or = C20) omega-6 and omega-3 fatty acids in cell membrane phospholipids, as well as with a depletion of antioxidant status, associated with a reduction of alpha-tocopherol in plasma lipoproteins. Infusions of the mixed medium-chain triglycerides (MCT)/LCT (50%:50%; wt:wt) largely bypass these disadvantages. In addition, plasma elimination of MCT/LCT is faster than that of LCT. Recent advances indicate a great potential for omega-3 FAs incorporated into membrane phospholipids to modulate cell response to various stimuli and to influence several intracellular metabolic processes. Furthermore, some of these FA directly influence the production and the action of important mediators, the eicosanoids. In practical terms, an increased intake of omega-3 FAs may reduce inflammatory and thrombotic responses while protecting tissue microperfusion and immune defenses. Such properties may find interesting applications in several types of intensive care unit patients, provided that omega-3 FA incorporation takes place promptly. We recently had the opportunity to study in vitro and in vivo the metabolism of emulsions made of a mixture of MCT, soybean LCT, and fish oil triglycerides. Plasma elimination of such preparations appeared to be very fast, and their infusion was not associated with a prolonged residence of emulsion particles. In addition, uptake of remnants enriched with omega-3 FAs and liposoluble vitamins was fairly fast and occurred in several types of cells, leading to an efficient incorporation of omega-3 FAs in cell membranes within a few hours. The understanding that remnant uptake plays a significant role in the delivery of components included in lipid emulsions opens new areas of investigation and is likely to find several conditions of applications for new types of preparations.

Retroperitoneoscopic lumbar sympathectomy with balloon dissection: clinical experience.

PURPOSE: To describe our technique and clinical experience of retroperitoneoscopic lumbar sympathectomy with balloon dissection. PATIENTS AND METHODS: From 1995 to 1999, 23 procedures were performed. RESULTS: No complications were noted. The median hospital stay was 4 days. Of the 23 attempts, 2 had to be converted to open technique. Histologic examination demonstrated interruption of the sympathetic chain in 22 of the 23 cases and absence of nervous tissue in 1. CONCLUSIONS: Once the technique is mastered, it can be performed fast, and it offers patients the benefits of a minimally invasive approach without the inconsistent therapeutic results of chemical sympathectomy.

Acute pneumoperitoneum without peritonitis. A case report.

An uncommon case of pneumoperitoneum without peritonitis, related to small bowel diverticulosis is presented. Pneumoperitoneum is usually a life-threatening incident, most frequently attributed to a perforated viscus and generally requiring emergency surgery. Non surgical pneumoperitoneum, however, is known to be caused by a variety of pathological and non pathological entities. Small bowel diverticulosis is an extremely rare cause of chronic pneumoperitoneum without peritonitis. In the presence of mechanical bowel obstruction, the latter kind of pneumoperitoneum can suddenly become impressively increased. A conservative attitude is generally advocated in the presence of such a benign pneumoperitoneum. However, laparoscopic exploration may be helpful for the diagnosis.

Gastric volvulus as a complication of a left superior lobectomy in a patient with pre-existing hiatal hernia.

The case of a 75-year-old man with a history of hiatal hernia, who develops an acute gastric volvulus 17 days after a superior lobectomy of the left lung, is described. No similar cases were found in literature.

Telangiectatic osteogenic sarcoma: an unusual presentation.

The authors present a case of telangiectatic osteogenic sarcoma of unusual radiographic presentation. The lesion presents as a slow growing, rather "benign" tumor, while most osteosarcomas usually present as osteolytic lesions of which the radiological aspect allows the diagnosis of malignancy with certainty.

Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis.

OBJECTIVE: To assess the relative risk of perinatal mortality, severe preterm delivery, and low birth weight associated with previous treatment for precursors of cervical cancer. DATA SOURCES: Medline and Embase citation tracking from January 1960 to December 2007. Selection criteria Eligible studies had data on severe pregnancy outcomes for women with and without previous treatment for cervical intraepithelial neoplasia. Considered outcomes were perinatal mortality, severe preterm delivery (<32/34 weeks), extreme preterm delivery (<28/30 weeks), and low birth weight (<2000 g, <1500 g, and <1000 g). Excisional and ablative treatment procedures were distinguished. RESULTS: One prospective cohort and 19 retrospective studies were retrieved. Cold knife conisation was associated with a significantly increased risk of perinatal mortality (relative risk 2.87, 95% confidence interval 1.42 to 5.81) and a significantly higher risk of severe preterm delivery (2.78, 1.72 to 4.51), extreme preterm delivery (5.33, 1.63 to 17.40), and low birth weight of <2000 g (2.86, 1.37 to 5.97). Laser conisation, described in only one study, was also followed by a significantly increased chance of low birth weight of <2000 g and <1500 g. Large loop excision of the transformation zone and ablative treatment with cryotherapy or laser were not associated with a significantly increased risk of serious adverse pregnancy outcomes. Ablation by radical diathermy was associated with a significantly higher frequency of perinatal mortality, severe and extreme preterm delivery, and low birth weight below 2000 g or 1500 g. CONCLUSIONS: In the treatment of cervical intraepithelial neoplasia, cold knife conisation and probably both laser conisation and radical diathermy are associated with an increased risk of subsequent perinatal mortality and other serious pregnancy outcomes, unlike laser ablation and cryotherapy. Large loop excision of the transformation zone cannot be considered as completely free of adverse outcomes.