[A rare localization of annular pancreas at the pars horizontalis duodeni--case report]

Annular pancreas is a rare congenital malformation of the pancreas. In about 50 % of the cases the malformation is asymptomatic until the second to fifth decade. We report on a 75-year-old male patient with an extremely rare localization of annular pancreas - namely at the pars horicontalis duodeni - who presented with recurrent vomiting and loss of weight. An end-to-side Roux-Y duodenojejunostomy was performed. After that procedure we discharged the patient on day eleven after surgery in good physical health condition. In a patient presenting signs of duodenal obstruction annular pancreas should be taken into account as a possibility.

Retention of surgery specialists in academia: a critical agenda

Recruitment and retention of specialists to academia appears to be a growing problem in university teaching hospitals. Members of the American College of Veterinary Surgeons (ACVS) believe that the movement of surgery specialists to practice may have an impact on the training of veterinary students and surgery residents. To address these concerns, 1,071 ACVS diplomates and 60 department heads and hospital directors from all veterinary schools in North America were surveyed to determine whether a problem exists, the extent of the problem, and potential reasons for migration of specialists to practice. Responses were obtained from 620 ACVS diplomates (58 per cent) and 38 department heads and hospital directors (63%) from 28 different universities. The responses confirmed a net movement of surgery specialists from academia to practice. Eighty seven percent of department heads and hospital directors believed there was a shortage of small animal surgery specialists in academia; this information was supported by the fact that 47% responded that they had open positions and 68% had difficulty filling positions in the last five years. The demand was slightly less for large animal surgery specialists, and 42 per cent of respondents indicated that they had open positions. Financial considerations were the most common reason for surgery specialists to move from academia to private practice. Seventy-six percent of responding ACVS diplomates in private practice had a total compensation package valued at greater than $125,000 per year, whereas 77.8% of diplomates in academia had total compensation valued at $125,000 or less. Most universities offer starting salaries (not including benefits) for recently certified surgery specialists ranging from $70,000 to $90,000. Reasons for moving from academia to practice besides financial considerations included undesirable location of university hospitals; lack of interest in research; and a belief that university administration was not supportive of surgery specialists. Many academic surgery specialists were frustrated by the requirement for productivity in research, teaching, and service for promotion in tenure-track positions.

Coxofemoral Arthroscopy and Total Hip Arthroplasty for Management of Intermediate Grade Fibrosarcoma in a Dog

OBJECTIVE

To report the use of arthroscopy and total hip arthroplasty (THA) for management of intermediate grade fibrosarcoma of the femoral head in a dog.

STUDY DESIGN

Clinical case report.

ANIMAL

A 6-year-old spayed female Rottweiler presented for evaluation of acute-onset of lameness of the right pelvic limb of approximately 10 days duration.

METHODS

Coxofemoral arthroscopy was performed to obtain fine needle aspiration and Jamshidi biopsy of a lytic lesion of the femoral head. A cemented THA was performed removing as much of the femoral neck and proximal femur as possible while not compromising implant or joint stability.

RESULTS

Histologic evaluation of specimens from the femoral head and neck remnants confirmed an intermediate grade fibrosarcoma. Fifteen months after THA, subjectively there was normal use of the right limb with only limited decrease in range of motion and mild muscular atrophy. Radiographs demonstrated stationary positioning of the THA implants.

CONCLUSIONS

Arthroscopy of the coxofemoral joint is an effective diagnostic tool for evaluation of disease of the articular structures and canine total hip replacement may be an appropriate means of limb salvage in rare cases of disease of the femoral head.

CLINICAL RELEVANCE

This case provides support for the use of coxofemoral arthroscopy as a diagnostic tool as well as an aid in acquiring representative intraarticular tissue samples. Additionally, the case presented demonstrates the potential use of THA as a limb sparing technique in cases of disease affecting the femoral head of dogs.

Immediate postabortal insertion of intrauterine devices

BACKGROUND

Insertion of an intrauterine device (IUD) immediately after an abortion has several potential advantages. The woman is known not to be pregnant, a major concern for clinicians. For example, many clinicians refuse to insert an IUD in a woman who is not menstruating. After induced abortion, a woman's motivation to use contraception may be high. However, insertion of an IUD immediately after a pregnancy ends carries potential risks as well. For example, the risk of spontaneous expulsion may be increased due to recent cervical dilation.

OBJECTIVES

To assess the safety and efficacy of IUD insertion immediately after spontaneous or induced abortion.

SEARCH STRATEGY

We used MEDLINE, Popline, and EMBASE computer searches, supplemented by review articles and contacts with investigators.

SELECTION CRITERIA

We sought all randomized controlled trials that had at least one treatment arm that involved IUD insertion immediately after an induced abortion or after curettage for spontaneous abortion. We identified 12 trials which described random assignment but excluded three from this review. Two of these revealed unethical research conduct, and one used alternate assignment to treatments.

DATA COLLECTION AND ANALYSIS

We evaluated the methodological quality of each report and abstracted information onto a data collection form. We focused on gross discontinuation rates (single-decrement life table analysis) for accidental pregnancy, perforation, expulsion, and pelvic inflammatory disease. We entered the data into RevMan 3.1 for analysis of Peto odds ratios.

MAIN RESULTS

In large multicenter trials, the TCu 220C device proved superior to either the Lippes Loop D or the Copper 7 IUDs for immediate postabortal insertion. In single-center trials, the Nova T IUD had a significantly higher discontinuation rate for pregnancy than did the Multiload 250 (OR 4.5; 95% CI 1.0-19.8), while the Nova T had a significantly lower discontinuation rate for pregnancy than did the TCu 200 (OR 0.3; 95% CI 0.1-0.9). The levonorgestrel-releasing device was more effective in preventing pregnancy than was the Nova T. Only one trial compared immediate vs. delayed insertion. In this trial, the performance of the Copper 7 IUD inserted immediately after abortion was inferior to that after interval insertion (remote from pregnancy), although the differences were not statistically significant.

REVIEWERS' CONCLUSIONS

Insertion of an IUD immediately after abortion is both safe and practical. IUD expulsion rates appear higher than after interval insertions.

Steroid hormones for contraception in men

BACKGROUND

Male hormonal contraception has been an elusive goal. Administration of sex steroids to men can shut off sperm production through effects on the pituitary and hypothalamus. However, this approach also decreases production of testosterone, so "add-back" therapy is needed.

OBJECTIVES

To summarize all randomized controlled trials of male hormonal contraception.

SEARCH STRATEGY

We searched the computerized databases Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Popline, and LILACS (each from inception to February, 2003) for randomized controlled trials of hormonal contraception in men. We wrote to authors of identified trials to seek unpublished or published trials that we might have missed.

SELECTION CRITERIA

We included all randomized controlled trials in any language that compared a steroid hormone with another contraceptive. We excluded non-steroidal male contraceptives, such as gossypol. We included both placebo and active-regimen control groups. All trials identified included only healthy men with normal semen analyses.

DATA COLLECTION AND ANALYSIS

Azoospermia (absence of spermatozoa on semen examination) was the primary outcome measure. Data were insufficient to examine pregnancy rates and side effects.

MAIN RESULTS

The proportion of men who achieved azoospermia varied widely in reports to date. Few significant differences emerged from these trials. Levonorgestrel implants combined with injectable testosterone enanthate (100 mg IM) was significantly more effective than was levonorgestrel 125 mcg by mouth daily combined with testosterone patches (10 mg/d) (OR for azoospermia with the oral levonorgestrel regimen 0.03; 95%CI 0.00-0.29). The addition of levonorgestrel 500 mcg by mouth daily improved the effectiveness of testosterone enanthate 100 mg IM weekly by itself (OR for azoospermia with the combined regimen 4.0; 95%CI 1.00-15.99). Several regimens, including testosterone alone and GnRH agonists and antagonists, had disappointing results.

REVIEWERS' CONCLUSIONS

No male hormonal contraceptive is ready for clinical use. All trials published to date have been small exploratory studies. As a result, their power to detect important differences has been limited and their results imprecise. In addition, the definition of oligospermia has been imprecise or inconsistent in many reports. To avoid bias, future trials need more attention to the methodological requirements for randomized controlled trials. Trials with adequate power would also be helpful.

Characterization and Dissolution Behavior of Sputtered Calcium Phosphate Coatings After Different Postdeposition Heat Treatment Temperatures

There is a lack of correlation between specific properties of hydroxyapatite coating surfaces, osseointegration processes, and implant success. The aim of this study was to evaluate the relationship between well-characterized structural and chemical properties of radio-frequency sputtered calcium phosphate (CaP) coatings and their dissolution behavior. Sputtered CaP coatings were evaluated as-sputtered (non-heat treated) or after 1 hour of postsputter heat treatments at 400 degrees C or 600 degrees C. All coatings were characterized by X-ray diffraction, X-ray photoelectron spectroscopy, Fourier transform infrared spectroscopy, and contact angle measurement. The dissolution behavior of CaP coatings in the presence and absence of proteins was also investigated. It was observed from this study that as-sputtered CaP coatings were amorphous. The 400 degrees C heat-treated CaP coatings exhibited low crystallinity (1.9% +/- 0.4%), whereas the 600 degrees C heat-treated CaP coatings were highly crystalline (67.0% +/- 2.4%). The increase of Ca/P ratio, PO4/HPO4 ratio, and the number of PO4 peaks were observed to be consistent with the increase in heating temperature and the degrees of coating crystallinity. Phosphorus ions released from CaP coatings decreased with the increase of crystallinity of CaP coatings. In addition, immersion of CaP coatings in media containing proteins resulted in an increase in P ions released as compared with coatings immersed in media without proteins. It was concluded that the degree of CaP coating crystallinity can be controlled by varying the postdeposition heat-treatment temperature. It was also concluded that, aside from coating crystallinity, dissolution and reprecipitation of the coatings can be controlled by knowing the presence of proteins in the media and PO4/HPO4 ratio within the coatings.

Immediate post-partum insertion of intrauterine devices

BACKGROUND

Insertion of an intrauterine device (IUD) immediately after delivery is appealing for several reasons. The woman is known not to be pregnant, her motivation for contraception may be high and the setting may be convenient for both the woman and her provider. However, the risk of spontaneous expulsion may be unacceptably high.

OBJECTIVES

To assess the efficacy and feasibility of IUD insertion immediately after expulsion of the placenta. Our a priori hypothesis was that this practice is safe but associated with higher expulsion rates than interval IUD insertion.

SEARCH STRATEGY

We used MEDLINE, Popline, EMBASE, and Cochrane Controlled Trials Register computer searches, supplemented by review articles and contact with investigators.

SELECTION CRITERIA

We sought all randomized controlled trials that had at least one treatment arm that involved immediate post-partum (within ten minutes of placental expulsion) insertion of an IUD. Comparisons could include different IUDs, different insertion techniques, immediate vs. delayed post-partum insertion, or immediate vs. interval insertion (unrelated to pregnancy). Studies could include either vaginal or cesarean deliveries.

DATA COLLECTION AND ANALYSIS

We evaluated the methodological quality of each report and sought to identify duplicate reporting of data from multicenter trials. We abstracted data onto data collection forms. Principal outcome measures included pregnancy, expulsion, and continuation rates. Because the trials did not have uniform interventions, we were unable to aggregate them in a meta-analysis.

MAIN RESULTS

We found no randomized controlled trials that directly compared immediate post-partum insertion with either delayed post-partum or interval insertion. Modifications of existing devices, such as adding absorbable sutures or additional appendages, did not appear beneficial. Most studies showed no important differences between insertions done by hand or by instruments. Lippes Loops and Progestasert devices did not perform as well as did copper devices.

REVIEWER'S CONCLUSIONS

Immediate post-partum insertion of IUDs appeared safe and effective, though direct comparisons with other insertion times were lacking. Advantages of immediate post-partum insertion include high motivation, assurance that the woman is not pregnant, and convenience. However, expulsion rates appear to be higher than with interval insertion. The popularity of immediate post-partum IUD insertion in countries as diverse as China, Mexico, and Egypt support the feasibility of this approach. Early follow-up may be important in identifying spontaneous IUD expulsions.

Immediate post-partum insertion of intrauterine devices: a Cochrane review

BACKGROUND

Insertion of an intrauterine device (IUD) immediately after delivery is appealing for several reasons. The woman is known not to be pregnant, her motivation for contraception may be high and the setting may be convenient for both the woman and her provider. However, the risk of spontaneous expulsion may be unacceptably high. The objective of this study was to assess the efficacy and feasibility of IUD insertion immediately after expulsion of the placenta. Our a priori hypothesis was that this practice is safe, but associated with higher expulsion rates than interval IUD insertion.

METHODS

We used Medline, Popline, Embase, and Cochrane Controlled Trials Register computer searches, supplemented by review articles and contact with investigators. We sought all randomized controlled trials that had at least one treatment arm that involved immediate post-partum (within 10 min of placental expulsion) insertion of an IUD. Comparisons could include different IUDs, different insertion techniques, immediate versus delayed post-partum insertion, or immediate versus interval insertion (unrelated to pregnancy). Studies could include either vaginal or Caesarean deliveries. We evaluated the methodological quality of each report and sought to identify duplicate reporting of data from multicentre trials. We abstracted data onto data collection forms. Principal outcome measures included pregnancy, expulsion and continuation rates. Because the trials did not have uniform interventions, we were unable to aggregate them in a meta-analysis.

RESULTS

We found no randomized controlled trials that directly compared immediate post-partum insertion with either delayed post-partum or interval insertion. Modifications of existing devices, such as adding absorbable sutures or additional appendages, did not appear beneficial. Most studies showed no important differences between insertions done by hand or by instruments. Lippes Loops and Progestasert devices did not perform as well as copper devices.

CONCLUSIONS

Immediate post-partum insertion of IUDs appeared safe and effective, though direct comparisons with other insertion times were lacking. Advantages of immediate post-partum insertion include high motivation, assurance that the woman is not pregnant, and convenience. However, expulsion rates appear to be higher than with interval insertion. The popularity of immediate post-partum IUD insertion in countries as diverse as China, Mexico and Egypt support the feasibility of this approach. Early follow-up may be important in identifying spontaneous IUD expulsions.

Immediate postabortal insertion of intrauterine devices

BACKGROUND

Insertion of an intrauterine device (IUD) immediately after an abortion has several potential advantages. The woman is known not to be pregnant, a major concern for clinicians. For example, many clinicians refuse to insert an IUD in a woman who is not menstruating [Stanback 1997]. After induced abortion, a woman's motivation to use contraception may be high. Among women who have limited access to a clinician, abortion care may provide a unique opportunity to address a woman's need for contraception [Mahomed 1997; McLaurin 1993; Wolf 1994]. A copper IUD confers nearly the same contraceptive efficacy as does tubal sterilization [Peterson 1996], yet it is simpler, less expensive, and promptly reversible. In addition, insertion of an IUD immediately after abortion may avoid discomfort related to insertion, and any bleeding from the insertion will be disguised by the expected bleeding after abortion. However, insertion of an IUD immediately after a pregnancy ends carries potential risks as well. For example, the risk of perforation may be increased due to softening of the myometrium. One IUD manufacturer in the United States warns that "The PROGESTASERT(R) system is not intended for immediate postabortion or postpartum insertion It should not be inserted until involution of the uterus is complete. The incidence of perforation and expulsion is greater if involution is not completed." [ALZA 1998] The package labeling for the Copper 7 stated that it should not be inserted after an abortion until involution was complete "in order to avoid a higher incidence of perforation or expulsion."[Gillett 1980] Another potential concern is infection. Insertion of an IUD after a clandestine or unsafe abortion may increase the risk of upper genital tract infection compared with interval insertion (remote from pregnancy).

OBJECTIVES

To assess the safety and efficacy of IUD insertion immediately after spontaneous or induced abortion.

SEARCH STRATEGY

We used Medline, Popline, and EMBASE computer searches, supplemented by review articles and contacts with investigators.

SELECTION CRITERIA

We sought all randomized controlled trials that had at least one treatment arm that involved IUD insertion immediately after an induced abortion or after curettage for spontaneous abortion. We identified 12 trials which described random assignment but excluded three from this review. Two of these revealed unethical research conduct, and one used alternate assignment to treatments.

DATA COLLECTION AND ANALYSIS

We evaluated the methodological quality of each report and abstracted information onto a data collection form. We focused on gross discontinuation rates (single-decrement life table analysis) for accidental pregnancy, perforation, expulsion, and pelvic inflammatory disease. We entered the data into RevMan 3.1 for analysis of Peto odds ratios.

MAIN RESULTS

In large multicenter trials, the TCu 220C device proved superior to either the Lippes Loop D or the Copper 7 IUDs for immediate post-abortal insertion. The Peto OR for discontinuation for pregnancy was 0.4 (95% CI 0.2-0.7) compared with the Lippes Loop D and 0.5 (95% CI 0.3-0.8) compared with the Copper 7. Expulsions were also significantly less common with the TCu 220C than with the other two IUDs. In single-center trials, the Nova T IUD had a signicantly higher discontinuation rate for pregnancy than did the Multiload 250 (OR 4.5; 95% CI 1.0-19.8), while the Nova T had a significantly lower discontinuation rate for pregnancy than did the TCu 200 (OR 0.3; 95% CI 0.1-0.9). Only one trial compared immediate vs. delayed insertion. In this trial, the performance of the Copper 7 IUD inserted immediately after abortion was inferior to that after interval insertion (remote from pregnancy), although the differences were not statistically significant. Addition of copper sleeves to a Lippes Loop D improved its performance, but addition of a topical hydrogel to a Spring Coil did not offer benefit. Overall, rates of perforation and pelvic inflammatory disease were low.

REVIEWER'S CONCLUSIONS

Insertion of an IUD immediately after abortion is both safe and practical. This was true for both induced and reported "spontaneous" abortions, many of which may have been induced under clandestine circumstances. IUD expulsion rates were higher after second-trimester abortions than after earlier abortions, so delaying insertion may be advisable after later abortions. Although Copper 7 devices inserted unrelated to pregnancy may perform better than those inserted after abortion, many women who express interest in intrauterine contraception do not return for the scheduled insertion. These women may remain unprotected against unintended pregnancy. However, evidence is inadequate to compare the safety and efficacy of IUD insertion immediately after abortion vs. insertion some weeks later.

WHO multicentre randomised trial of misoprostol in the management of the third stage of labour

BACKGROUND

Postpartum haemorrhage is a leading cause of maternal morbidity and mortality. Active management of the third stage of labour, including use of a uterotonic agent, has been shown to reduce blood loss. Misoprostol (a prostaglandin E1 analogue) has been suggested for this purpose because it has strong uterotonic effects, can be given orally, is inexpensive, and does not need refrigeration for storage. We did a multicentre, double-blind, randomised controlled trial to determine whether oral misoprostol is as effective as oxytocin during the third stage of labour.

METHODS

In hospitals in Argentina, China, Egypt, Ireland, Nigeria, South Africa, Switzerland, Thailand, and Vietnam, we randomly assigned women about to deliver vaginally to receive 600 microg misoprostol orally or 10 IU oxytocin intravenously or intramuscularly, according to routine practice, plus corresponding identical placebos. The medications were administered immediately after delivery as part of the active management of the third stage of labour. The primary outcomes were measured postpartum blood loss of 1000 mL or more, and the use of additional uterotonics without an unacceptable level of side-effects. We chose an upper limit of a 35% increase in the risk of blood loss of 1000 mL or more as the margin of clinical equivalence, which was assessed by the confidence interval of the relative risk. Analysis was by intention to treat.

FINDINGS

9264 women were assigned misoprostol and 9266 oxytocin. 37 women in the misoprostol group and 34 in the oxytocin group had emergency caesarean sections and were excluded. 366 (4%) of women on misoprostol had a measured blood loss of 1000 mL or more, compared with 263 (3%) of those on oxytocin (relative risk 1.39 [95% CI 1.19-1.63], p<0.0001). 1398 (15%) women in the misoprostol group and 1002 (11%) in the oxytocin group required additional uterotonics (1.40 [1.29-1.51], p<0.0001). Misoprostol use was also associated with a significantly higher incidence of shivering (3.48 [3.15-3.84]) and raised body temperature (7.17 [5.67-9.07]) in the first hour after delivery.

INTERPRETATION

10 IU oxytocin (intravenous or intramuscular) is preferable to 600 microg oral misoprostol in the active management of the third stage of labour in hospital settings where active management is the norm.

A Novel Pathway Regulating Lipopolysaccharide-Induced Shock by ST2/T1 Via Inhibition of Toll-Like Receptor 4 Expression

ST2/ST2L, a member of the IL-1R gene family, is expressed by fibroblasts, mast cells, and Th2, but not Th1, cells. It exists in both membrane-bound (ST2L) and soluble forms (ST2). Although ST2L has immunoregulatory properties, its ligand, cellular targets, and mode of action remain unclear. Using a soluble ST2-human IgG fusion protein, we demonstrated that ST2 bound to primary bone marrow-derived macrophages (BMM) and that this binding was enhanced by treatment with LPS. The sST2 treatment of BMMs inhibited production of the LPS-induced proinflammatory cytokines IL-6, IL-12, and TNF-alpha but did not alter IL-10 or NO production. Treatment of BMMs with sST2 down-regulated expression of Toll-like receptors-4 and -1 but induced nuclear translocation of NF-kappaB. Administration of sST2 in vivo after LPS challenge significantly reduced LPS-mediated mortality and serum levels of IL-6, IL-12, and TNF-alpha. Conversely, blockade of endogenous ST2 through administration of anti-ST2 Ab exacerbated the toxic effects of LPS. Thus, ST2 has anti-inflammatory properties that act directly on macrophages. We demonstrate here a novel regulatory pathway for LPS-induced shock via the ST2-Toll-like receptor 4 route. This may be of considerable therapeutic potential for reducing the severity and pathology of inflammatory diseases.

Oesophageal candidosis in intensive care patients

We conducted upper intestinoscopies in 124 intensive care patients, six of whom had oesophageal candidosis. Of these, two also had Candida plaque in the stomach. The patients at the intensive care unit (ICU) had a mean Apache-II score of 26.7; whereas the score was 29.5 in patients with Candida oesophagitis. A significant increase of Candida antibodies was found in 59 of 124 patients (47.6%), including all patients with oesophageal candidosis. Presumably, mycotic infections of other sites were present. The severity by which mucous membranes were affected correlated well with microscopically evident invasiveness.

Characterization of epidemic and nonepidemic methicillin-resistant Staphylococcus aureus strains in a university hospital in northeast Germany

The aim of this study was to analyze methicillin-resistant Staphylococcus aureus strains isolated during a 1-year period by means of pulsed-field gel electrophoresis, resistance phenotyping and determination of biochemical features. Eight different resistance phenotypes with the predominant resistance type Pen Oxa Cip (penicillin, oxacillin, ciprofloxacin) were observed. None of the strains tested exhibited decreased susceptibility to vancomycin, but two strains were resistant to mupirocin. Genetic relatedness of methicillin-resistant Staphylococcus aureus isolates could be shown for two outbreaks, one of which was caused by a clone with an epidemic potential concerning duration of colonization/infection of patients and dissemination of the strains in the hospital.