Recovery from vaginal hysterectomy compared with laparoscopy-assisted vaginal hysterectomy: a prospective, randomized, multicenter study

OBJECTIVE

To evaluate short-term recovery of vaginal hysterectomy with those of laparoscopic assisted vaginal hysterectomy performed in a prospective, randomized multicentric study.

STUDY DESIGN

Eighty patients referred for hysterectomy for benign pathology were randomized to either vaginal hysterectomy (40 patients) or laparoscopic assisted vaginal hysterectomy (40 patients). Inclusion criteria were uterine size larger than 280 g and one or more of the following: previous pelvic surgery, history of pelvic inflammatory disease, moderate or severe endometriosis, concomitant adnexal masses, and indication for adnexectomy. No upper limit of uterine size was set. All the laparoscopic and the vaginal hysterectomies were done under endotracheal general anesthesia.

RESULTS

There was no statistically significant difference in terms of patient's age, parity, postmenopausal state, indication for surgery and mean uterine weight between the 2 groups. Laparoconversion was performed in three women in the laparoscopic group. Operative time was significantly shorter in the vaginal versus the laparoscopic groups 108+/-35 and 160+/-50 respectively (p<0.001). The use of paracetamol, non steroidal anti-inflammatory drugs, and opioid during hospitalization were similar in the 2 groups. There was no difference in the 1st day hemoglobin level drop, time of passing gas and stool, or hospital stay between the 2 groups.

CONCLUSION

In contrast with earlier reports, there was no difference in short-term recovery between patients undergoing vaginal or laparoscopic hysterectomy. No advantage was found performing laparoscopic assisted vaginal hysterectomy in comparison with the standard vaginal hysterectomy.

Ecosystem respiration in a young ponderosa pine plantation in the Sierra Nevada Mountains, California

We estimated total ecosystem respiration from a ponderosa pine (Pinus ponderosa Dougl. ex Laws.) plantation in the Sierra Nevada Mountains near Georgetown, California, from June to October, 1998. We apportioned ecosystem respiration among heterotrophic, root, stem and foliage based on relationships for each component that considered microclimate and vegetation characteristics. We measured each respiration component at selected sampling points, and scaled the measurements up to the ecosystem based on modeled relationships. Over the study period, total mean ecosystem respiration was 5.7 +/- 1.3 mumol m-2 s-1 (based on daily mean), comprising about 67% from soil-surface CO2 efflux, 10% from stem and branch respiration and 23% from foliage respiration. Shrub leaves contributed about 24% to total foliage respiration, and current-year needles (1998 age class) accounted for 40% of total tree needle respiration. Root respiration accounted for 47% of soil-surface CO2 efflux. We conclude that ecosystem respiration can be estimated based on daily mean air and soil temperatures through exponential relationships with r2 values of 0.85 and 0.87, respectively. When based on both air and soil temperatures, about 91% of the variation in total ecosystem respiration could be explained by a linear regression.

Errors in ultrasound digital image distance measurements

Digital image distance measurements have two sources of error: they are the inherent image pixelation error and modality-specific registration errors. A theoretical analysis was performed to determine the pixelation error uncertainty in ultrasound (US) clinical and phantom digital image distance measurements. For horizontal or vertical phantom image distance measurements, the average absolute image pixelation error was found to be 0.5 pixel width. In the clinical horizontal case, the combined absolute distance measurement error due to pixel size and operator cursor placement errors was found to be 1.5 pixel widths (for a cursor placement error of 1 pixel width). For image clinical distance measurements, a formula is given for the dependence of the measurement error on the inclination of the measured structure in the pixel matrix. A protocol is recommended that minimizes all sources of error in clinical image distance measurements.

The effect of acoustic velocity on phantom measurements

Urethane rubber ultrasound (US) phantoms have a much lower acoustic velocity (1430-1450 m/s) than the accepted soft tissue average of 1540 m/s. Two important questions arise: can the rod positions in these rubber phantoms be adjusted so that they may be used to test equipment distance measurement accuracy for all types of multielement transducers, and can they be used to measure beam focus (using the spread of the rod blur patterns)? These questions were addressed for linear-, phased-, convex- and vector-array transducers. Theoretical predictions for the different transducers' distance measurement errors agreed with careful measurements obtained with a specially designed array of stainless-steel rods immersed in paraffin oil (1447 m/s). The conclusions of this study are that phantoms with acoustic velocities different from 1540 m/s cannot be used to check distance measurement accuracies of all the types of real-time transducers, nor to predict a transducer's focusing performance in clinical scans.

Preventing postoperative pain by local anesthetic instillation after laparoscopic gynecologic surgery: a placebo-controlled comparison of bupivacaine and ropivacaine

We tested the hypothesis that local anesthetics instilled at the end of laparoscopic gynecologic procedures are able to prevent postoperative pain at wake-up and during the first 24 h. A total of 180 patients were randomly assigned into three groups to receive an intraperitoneal instillation of 20 mL of either bupivacaine 0.5% (Group B), ropivacaine 0.75% (Group R) or saline (Group S) at the end of surgery. All patients received analgesia with acetaminophen and ketoprofen IV infusions. Pain was assessed by using a 0-10 graded numerical scale (NS) every 5 min in the postanesthesia care unit and IV morphine was administered if NS was >4. Assessment of pain was continued every 4 h on the ward, and subcutaneous morphine was injected if needed to keep the NS score < 4. Postoperative nausea and vomiting (PONV) was rated on a 4-point scale. The morphine consumption at wake-up and over the first 24 h was significantly lower (P < 0.05) in Group B (mean, 0.92 mg at wake-up; 3.08 mg over 24 h) and in Group R (mean, 0.25 mg at wake-up; 0.69 mg over 24 h), than in Group S (mean, 4.18 mg at wake-up; 12.93 mg over 24 h). The morphine-sparing effect of ropivacaine was significantly greater than that of bupivacaine. Both local anesthetics were effective in the prevention of PONV. We concluded that local anesthetics should be instilled in all gynecologic patients at the end of all laparoscopic procedures.

IMPLICATIONS

Local anesthetic instillation (ropivacaine rather than bupivacaine) at the end of laparoscopy prevents postoperative pain and dramatically decreases the need for morphine. This technique, compared with placebo, is safe, improves patient comfort, shortens the stay in the postoperative care unit and decreases nursing care in the ward.

Forced expiratory flows and volumes in infants. Normative data and lung growth

Forced expiratory flows (FEF) can be measured in infants from lung volumes initiated near total lung capacity. In order to establish reference values and to evaluate lung growth, we obtained measurements in 155 healthy subjects between 3 and 149 wk of age. Forced vital capacity (FVC) was highly correlated with body length; however, after accounting for length, age was also significant. When subjects were divided at the median age (40 wk) younger compared with older subjects had a significantly larger slope for length (3.7 versus 2.8; p = 0.002). The flow parameters (FEF(50), FEF(75), FEF(85), and FEF(25-75)) were highly correlated with length, and those infants whose mothers smoked had lower flows. For FEF(75), male subjects had lower flows than female subjects. The relationship between FEF and volume was assessed using FEV(0.5)/FVC, which decreased with increasing length. Smaller subjects emptied their lung volume proportionately faster. We conclude that our study provides reference values for this age group and demonstrates that smoke-exposed infants and male subjects have decreased FEF. In addition, our findings indicate that lung volume increases most rapidly during the first year of life and that airways are large relative to lung volume very early in life.

The incidence, prevalence, and severity of sarcoidosis in New York City firefighters

OBJECTIVE

The etiology of sarcoidosis is unknown, but epidemiology suggests that environmental agents are a factor. Because firefighters are exposed to numerous toxins, we questioned whether sarcoidosis was increased in this cohort.

SETTING

The New York City Fire Department (FDNY), employing > 11,000 firefighters and nearly 3,000 emergency medical services (EMS) health-care workers (HCWs).

DESIGN

In 1985, FDNY initiated a surveillance program to determine the incidence, prevalence, and severity of biopsy-proven sarcoidosis in firefighters. In 1995, EMS HCWs were added as control subjects.

RESULTS

Between 1985 and 1998, 4 prior cases and 21 new cases of sarcoidosis were found in FDNY firefighters. Annual incidence proportions ranged from 0 to 43.6/100,000, and averaged 12.9/100,000. On July 1, 1998, the point prevalence was 222/100,000. For EMS HCWs, annual incidence proportions were zero. Radiographic stage 0 or stage 1 sarcoidosis was found in 19 firefighters (76%), and stage 3 was found in 1 firefighter (4%). Pulmonary function (FVC, FEV(1), and diffusing capacity for carbon monoxide) was normal in 17 firefighters (68%), and reduced to </= 65% predicted in 2 firefighters (8%). Maximum oxygen consumption (MVO(2)) was normal in 10 of 17 firefighters (59%), and reduced to 65% predicted in 3 firefighters (12%). Five of seven firefighters (71%) with abnormal MVO(2) had gas exchange abnormalities, and none had O(2) desaturation. All returned to fire fighting.

CONCLUSIONS

Annual incidence proportions and point prevalence were increased in FDNY firefighters as compared to EMS HCWs and historical controls. Radiographs and physiologic measurements demonstrated only minimal impairment.

Diabetes mellitus, other medical conditions and familial history of cancer as risk factors for pancreatic cancer

In a population-based case-control study of pancreatic cancer conducted in three areas of the USA, 484 cases and 2099 controls were interviewed to evaluate the aetiologic role of several medical conditions/interventions, including diabetes mellitus, cholecystectomy, ulcer/gastrectomy and allergic states. We also evaluated risk associated with family history of cancer. Our findings support previous studies indicating that diabetes is a risk factor for pancreatic cancer, as well as a possible complication of the tumour. A significant positive trend in risk with increasing years prior to diagnosis of pancreatic cancer was apparent (P-value for test of trend = 0.016), with diabetics diagnosed at least 10 years prior to diagnosis having a significant 50% increased risk. Those treated with insulin had risks similar to those not treated with insulin (odds ratio (OR) = 1.6 and 1.5 respectively), and no trend in risk was associated with increasing duration of insulin treatment. Cholecystectomy also appeared to be a risk factor, as well as a consequence of the malignancy. Subjects with a cholecystectomy at least 20 years prior to the diagnosis of pancreatic cancer experienced a 70% increased risk, which was marginally significant. In contrast, subjects with a history of duodenal or gastric ulcer had little or no elevated risk (OR = 1.2; confidence interval = 0.9-1.6). Those treated by gastrectomy had the same risk as those not receiving surgery, providing little support for the hypothesis that gastrectomy is a risk factor for pancreatic cancer. A significant 40% reduced risk was associated with hay fever, a non-significant 50% decreased risk with allergies to animals, and a non-significant 40% reduced risk with allergies to dust/moulds. These associations, however, may be due to chance since no risk reductions were apparent for asthma or several other types of allergies. In addition, we observed significantly increased risks for subjects reporting a first-degree relative with cancers of the pancreas (OR = 3.2), colon (OR = 1.7) or ovary (OR = 5.3) and non-significantly increased risks for cancers of the endometrium (OR = 1.5) or breast (OR = 1.3). The pattern is consistent with the familial predisposition reported for pancreatic cancer and with the array of tumours associated with hereditary non-polyposis colon cancer.

Cardiopulmonary and CD4 cell changes in response to exercise training in early symptomatic HIV infection

PURPOSE

The purposes of the present study were to assess the effects of a 12-wk laboratory based aerobic exercise program on cardiopulmonary function, CD4 cell count, and physician-assessed health status among symptomatic pre-AIDS HIV-infected individuals (N = 28) and to assess the degree to which ill health was associated with exercise relapse.

METHODS

Responses to graded exercise test, physician-assessed health status, and CD4 cell counts were determined at baseline and 12-wk follow-up for participants randomly assigned to exercise or control conditions, and reasons for exercise noncompliance were recorded.

RESULTS

Approximately 61% of exercise-assigned participants complied (> 50% attendance) with the exercise program, and analyses of exercise relapse data indicated that obesity and smoking status, but not exercise-associated illness, differentiated compliant from noncompliant exercisers. Compliant exercisers significantly improved peak oxygen consumption (VO2peak; 12%), oxygen pulse (O2pulse; 13%), tidal volume (TV; 8%), ventilation (VE; 17%), and leg power (25%) to a greater degree than control participants and noncompliant exercisers (all P < 0.05). Although no group differences in health status were found, a significant interaction effect indicated that noncompliant exercisers' CD4 cells declined (18%) significantly, whereas compliant exercisers' cell counts significantly increased (13%; P < 0.05).

CONCLUSION

We conclude that although aerobic exercise can improve cardiopulmonary functioning in symptomatic HIV-infected individuals with minimal health risks, attention to factors associated with exercise adherence is warranted.

Activation of erythropoietin receptor in the absence of hormone by a peptide that binds to a domain different from the hormone binding site

Applying a homology search method previously described, we identified a sequence in the extracellular dimerization site of the erythropoietin receptor, distant from the hormone binding site. A peptide identical to that sequence was synthesized. Remarkably, it activated receptor signaling in the absence of erythropoietin. Neither the peptide nor the hormone altered the affinity of the other for the receptor; thus, the peptide does not bind to the hormone binding site. The combined activation of signal transduction by hormone and peptide was strongly synergistic. In mice, the peptide acted like the hormone, protecting against the decrease in hematocrit caused by carboplatin.

Methylphenidate treatment for bulimia nervosa associated with a cluster B personality disorder

OBJECTIVES

Psychotherapy and antidepressant medication are helpful to many patients with bulimia nervosa (BN). However, a substantial number of bulimics respond poorly to such treatments. Recent studies suggest that many of the poor responders have cluster B personality disorders. In some ways, the symptomatology of bulimics who have a comorbid cluster B disorder resembles that of patients with attention deficit hyperactivity disorder (ADHD). In particular, individuals in both groups frequently have a high level of impulsivity. Such a resemblance raised the question of whether administration of methylphenidate (MPH), a drug used to treat ADHD, would have therapeutic effects in this subgroup of BN patients.

METHODS

In a pilot study, we administered MPH to 2 patients with BN and cluster B traits and found beneficial effects. These patients had not responded to adequate trials of psychotherapy and selective serotonin reuptake inhibitors (SSRIs).

RESULTS

MPH treatment was effective. Both Patients had decreased binging and purging.

DISCUSSION

MPH may be useful for bulimics with cluster B personality disorder who respond poorly to conventional treatment. Further studies of MPH administration may be worthwhile. Due to the potential risks, however, clinical treatment with this agent is not recommended at this time.

[Pulmonary infection from Rhodococcus equi after renal transplantation. Review of the literature]

Rhodococcus Equi, a strictly aerobic Gram positive coco-bacillus, is a pathogen for horses and foals. It may induce opportunistic infections and is described in AIDS infected patients. We report the case of a 47-year old man, breeder of horses, with kidney transplant who has presented, 8 years after his graft, an impairment of health, a fever and evidence of pulmonary disease. The pulmonary biopsy under scanner guidance and microbiology study, has displayed the diagnosis of Rhodococcus equi infection. The evolution has been favorable with double antibiotherapy (follow-up 27 months). Ten comparable observations have been published after organ transplantation: (kidney: 8; heart: 1; liver: 1). Pulmonary locations are widely predominant. The animal contact is found only in 30% of cases. The presentation of the sickness has been compared to pulmonary tuberculosis or to nocardiosis, pathologies often observed in this context of immunosuppression. The antibiotic treatment is difficult and should required two bactericidal antibiotics. A surgical lobectomy can be envisaged in case of relapse. The mortality is 30%.

Cux/CDP homeoprotein is a component of NF-muNR and represses the immunoglobulin heavy chain intronic enhancer by antagonizing the bright transcription activator

Nuclear matrix attachment regions (MARs) flanking the immunoglobulin heavy chain intronic enhancer (Emu) are the targets of the negative regulator, NF-muNR, found in non-B and early pre-B cells. Expression library screening with NF-muNR binding sites yielded a cDNA clone encoding an alternatively spliced form of the Cux/CDP homeodomain protein. Cux/CDP fulfills criteria required for NF-muNR identity. It is expressed in non-B and early pre-B cells but not mature B cells. It binds to NF-muNR binding sites within Emu with appropriate differential affinities. Antiserum specific for Cux/CDP recognizes a polypeptide of the predicted size in affinity-purified NF-muNR preparations and binds NF-muNR complexed with DNA. Cotransfection with Cux/CDP represses the activity of Emu via the MAR sequences in both B and non-B cells. Cux/CDP antagonizes the effects of the Bright transcription activator at both the DNA binding and functional levels. We propose that Cux/CDP regulates cell-type-restricted, differentiation stage-specific Emu enhancer activity by interfering with the function of nuclear matrix-bound transcription activators.

The two-dimensional histogram as a constraint for protein phase improvement

The joint distribution of electron density and its gradient in a protein electron-density map was examined. This joint distribution was represented by a two-dimensional histogram (2D histogram) of electron-density values and the modulus of the gradient. 16 structures representing distinct protein-fold families were selected to study the dependence of the 2D histogram on resolution, overall temperature factor, structural conformation and phase error. The similarity between the histograms for a pair of structures was measured by correlation coefficient, and the residual provided a measure of the difference. The 2D histogram was found to vary with resolution and overall temperature factor, but was found to be insensitive to structure conformation. The average correlation coefficient between pairs of 2D histograms at three different resolutions examined was 0.90 with a standard deviation of 0.04. The average residual for the same condition was 0.13 with a standard deviation of 0.03. The 2D histogram was also found to be sensitive to phase error. The average correlation coefficient and residual between 2D histograms with 10 degrees phase difference are 0.71 and 0.18, respectively. The variation of the 2D histogram resulting from structure-conformation changes was estimated to be equivalent to that of a 4 degrees phase error. This establishes the minimal phase error that a 2D histogram-matching method could achieve. The conservation of the 2D histogram with respect to structure conformation enables the prediction of the ideal 2D histogram for unknown structures. The sensitivity of the 2D histogram to phase error suggests that it could be used as a target for the density-modification method and also could be used as a figure of merit for phase selection in ab initio phasing.

A comparison of forensic and nonforensic malingerers: a prototypical analysis of explanatory models

Explanatory models of malingering strive to understand the primary motivation underlying attempts to feign. Rogers, Sewell, and Goldstein (1994) provided empirical support for the conceptualization of pathogenic, criminological, and adaptational models. In the current study, a prototypical analysis of 221 forensic experts results in a slightly refined formulation: the adaptational models was decomposed into its two broad dimensions (cost-benefit analysis and adversarial setting). An important findings is that the factor structure for the explanatory models remained stable when applied to both forensic and nonforensic cases. As a first investigation, significant differences were observed in prototypical cases of malingering by the category of referral (forensic or nonforensic) and by type of feigning (mental disorders, cognitive impairment, and medical syndromes). Surprisingly, the feigning of medical syndromes appeared to play a relatively prominent role in both forensic and nonforensic cases and to be influenced by the apparent adversarial context of the assessment. Finally, important gender differences were observed, especially with nonforensic prototypical cases of malingering.

Correlation of color Doppler flow in the prostate with tissue microvascularity

BACKGROUND

The pathophysiology of increased color Doppler (CD) flow has not previously been addressed in histologic evaluations of microvascular parameters. In this study, the authors attempted to define the differences between benign and malignant biopsy cores found in regions of the prostate with normal and high CD flow.

METHODS

Forty patients were retrospectively chosen for CD histologic comparison, each of whom had a core from a sextant biopsy with the following characteristics: malignant tissue with distinct increased CD flow (n=11), malignant tissue with normal CD flow (n=10), benign tissue with distinctly increased CD flow (n=9), or benign tissue with normal CD flow (n=10). All biopsy cores were stained with factor VIII-related antigen to identify microvasculature and to determine the number of microvessels per square millimeter (mm2) in an average cross-sectional area of microvessels, the percentage of tissue occupied by microvasculature, and the Gleason score.

RESULTS

In biopsies of benign tissue, high CD flow was associated with greater numbers (P < 0.025) of vessels of similar size than in normal flow benign biopsies. Biopsies of malignant tissue contained significantly greater numbers (P < 0.01) of much smaller vessels (P < 0.0005) than biopsies of benign tissue. In biopsies of malignant tissue, no significant differences in microvasculature parameters were noted between high and normal CD flow, yet biopsies with high CD flow had average Gleason score of 6.7 compared with only 5.9 for biopsies with normal CD flow (P < 0.025).

CONCLUSIONS

Increased CD flow in biopsies of benign tissue was correlated with a greater number of vessels/mm2, yet all biopsies of malignant tissue had more vessels/mm2 than those of benign tissue. Increased CD flow in biopsies of malignant tissue cannot be explained by standard microvasculature analysis but significantly guides biopsies to regions with a greater Gleason score.

Panoramic radiology quality assessment

A procedure is proposed for performing noninvasive x-ray quality assessment tests on panoramic radiology equipment. A simple cardboard tube jig eliminates relative motion between the measurement system and the narrow, collimated x-ray beam. Accurate measurements of beam HVL, x-ray exposure coefficient of variation and mA linearity may be obtained. Use of the tube jig permits easy and routine monitoring of these important x-ray parameters as well as consistency checks of tube output. Film/screen contact also should be routinely checked in the clinic.