Laparoscopic management of ectopic pregnancy in the presence of a significant haemoperitoneum

OBJECTIVE

To assess the trend in the use of operative laparoscopy in the management of patients with ruptured ectopic pregnancy and significant haemoperitoneum.

METHOD

Four-year prospective observational study of the operative management of women with ruptured ectopic pregnancy and significant haemoperitoneum at the Whipps Cross University Hospital from January 2003 to December 2006. The inclusion criteria were patients with a clinical or laparoscopic assessment of significant haemoperitoneum (>800 ml). The amount of haemoperitoneum was determined at surgery.

RESULTS

The blood loss ranged from 800 to 3,500 ml. The laparoscopic approach in this specific clinical scenario increased from 40% in 2003 to 100% in 2006. In 2003 there were five patients, two (40%) were treated by laparoscopy, one (20%) was converted from laparoscopy to laparotomy and two (40%) had laparotomy. In 2004 there were six patients, five (85%) underwent laparoscopic management and one (15%) had laparotomy. In 2005 we had 14 patients, ten (72%) had laparoscopic management, 2 (14%) were converted to laparotomy and 2 (14%) had laparotomies. There were 12 patients in 2006 and all (100%) were treated by laparoscopy.

CONCLUSION

Our study demonstrates that with highly skilled anaesthetic and surgical teams, operative laparoscopy with its recognized advantages over laparotomy and is feasible in women with ruptured ectopic pregnancy and significant haemoperitoneum.

Sensitivity enhancement of SPR assay of progesterone based on mixed self-assembled monolayers using nanogold particles

Commercially available nanoparticles have been employed as high mass labels for enhancing the binding signals and improving the detection sensitivity of surface plasmon resonance (SPR) assays. Such a signal enhancement is affected by the size and distance of the nanoparticles from the sensing surface. High signal amplifications are expected with increasing nanoparticle size and as the distance between the sensing surface and the nanoparticle is decreased. This paper describes a new way to improve the SPR assay sensitivity of small molecules using a mixed self-assembled monolayer (mSAM) surface to bring the nanogold particles close to the sensing surface. Progesterone (P4) was conjugated to ovalbumin (OVA) with an oligoethylene glycol (OEG) linker to form protein conjugate (P(4)-OEG-OVA), which was immobilized onto the mSAM surface. Inhibition immunoassays based on this mSAM/P4-OEG-OVA surface have demonstrated that 10nm nanogold dramatically improved the assay sensitivity of progesterone, lowering its limit of detection (LOD) from the original 372.7 to 4.9 ng L(-1). In addition, the high stability of the mSAM/P4-OEG-OVA surface was demonstrated by the use of a single chip for over 400 binding/regeneration cycles without any significant drop in antibody binding capacity and baseline shift.

Influence of surgical preparation on the in-vivo response of osteochondral defects

Cartilage has an extremely poor capacity to heal, which has lead to intensive research into biomaterials and tissue engineering for the purpose of regenerating cartilage in vivo. Many of these techniques have shown great promise in vitro; however, the results do not always carry across to the in-vivo scenario. Healthy cartilage autografts often do not integrate with the adjacent cartilage, suggesting that cartilage is rarely capable of healing even under ideal conditions. It is hypothesized in this study that the surgical creation of defects in cartilage causes significant damage to the adjacent tissues, leading to further degradation of the cartilage and poor outcome for the repair in general. This study compares the healing response of osteochondral defects created with either a punch or a drill in the weight-bearing region of the sheep knee at 4 and 26 weeks following surgery. The use of a drill to create the defect creates a more aggressive inflammatory response at 4 weeks compared with a punch. However, by 26 weeks, defects created with a punch scored higher on the O'Driscoll cartilage grading scale. Tissue damage at the time of surgery plays an important part in the sequence of events for healing of cartilage defects. This knowledge will help to characterize and refine the ovine model for cartilage regeneration and may have an influence on surgical technique and instrumentation for clinical cartilage repair.

The efficacy of local anaesthetic for pain after iliac bone harvesting: a randomised controlled trial

INTRODUCTION

Autogenous bone grafting is commonly used in reconstructive surgery but postoperative pain from the donor site can be severe, delaying early mobilisation and preventing discharge from hospital.

METHOD

An RCT of levobupivacaine infusion (16.25mg/h for 24h) of iliac crest wounds versus placebo. Postoperative pain was recorded immediately on returning to the ward, then at 1, 2, 3, 4, 5, 6h, morning and evening on subsequent days until discharge, and at the 7-day clinic appointment. Mobility was recorded twice daily and at 7days.

RESULTS

Of 46 evaluable patients, 25 were randomised to levobupivacaine and 21 to placebo. Mean pain scores for (i) average pain from initial assessment to 6h; (ii) 1day in the morning; (iii) 1day in the evening; (iv) at 2days; and (v) follow-up were all statistically significant in favour of lower pain scores in the levobupivicaine group (p-values all <0.01). Comparison between the study groups for mobility found 6 patients unable to get out of bed in the placebo group and none in the local anaesthetic group at the initial assessment (Fisher's exact test p-value=0.005), and 2 patients at 24h. Patients in the local anaesthetic group were always more mobile and this was statistically significant even at 7days for gait disturbance, limp, deviation of gait and unequalness of stride. There were no complications relating to the infusion system.

CONCLUSIONS

Local anaesthetic significantly reduced postoperative pain and improved mobility. We recommend that surgeons use a local anaesthetic infusion to improve the postoperative experience for their patients undergoing iliac crest grafting.

Magnitude of progression-free survival (PFS) improvement and treatment (Tx) duration in metastatic colorectal cancer (mCRC) for bevacizumab (BV) in combination with oxaliplatin-containing regimens: An analysis of two phase III studies

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Background: In trials of BV with FOLFOX (fluorouracil, leucovorin, oxaliplatin) for mCRC, variability in the magnitude of PFS improvement has been reported [HR=0.61 in E3200 vs HR= 0.83 (FOLFOX or CAPOX (capecitabine and oxaliplatin)) in NO16966]. We propose that differences in rates of treatment discontinuation (D/C) for adverse events (AE) between these studies may have resulted in differences in the observed benefits associated with BV. We explored Tx duration (proportion of patients on Tx) and Tx D/C data at median PFS for the BV containing arms of each study. Methods: ECOG study E3200 randomized previously treated patients with mCRC to FOLFOX ± BV (10 mg/kg). NO16966 employed a 2x2 design that randomized previously untreated patients with mCRC to CAPOX vs FOLFOX and to BV (5 mg/kg) or placebo. In both trials, study Tx was defined as any component of the prescribed regimen. PFS was estimated from Kaplan-Meier curves, and hazard ratios (HR) for PFS were estimated by Cox regression. Results: Median PFS for the BV containing arm of the study: 30 weeks for E3200; 42 weeks for NO16966 Conclusion: These data suggest possible differences between the two studies in Tx duration and Tx D/C patterns with a greater proportion of patients on NO16966 discontinuing Tx for any AE. Duration of study Tx might have affected both the incidence of AEs and the magnitude of PFS benefit observed for the addition of bevacizumab to oxaliplatin-based chemotherapy in these studies. Attention to Tx duration and Non-PD Tx D/C in future clinical trials will be important when considering PFS as a primary efficacy endpoint.

[Table: see text]

No significant financial relationships to disclose.

Management of extra-tubal and rare ectopic pregnancies: case series and review of current literature

OBJECTIVE

Management of extra-tubal ectopic gestations remains an inadequately explored clinical field due to the rarity of the presentations. We present a synopsis of the management highlighted by our personal case series.

METHOD

A literature search was conducted through Pubmed and Medline databases. We reviewed all cases presenting with extra-tubal nidations in our institute, including seven interstitial, two cervical, three ovarian and two abdominal pregnancies.

RESULT

The advances in minimal access techniques and imaging modalities have resulted in novel fertility preserving endoscopic procedures. All except one of the patients were treated by endoscopic procedures, including a novel procedure for evacuation of cornual ectopics.

CONCLUSION

A high index of suspicion is essential, combined with meticulous review of clinical findings and imaging modalities to make an accurate diagnosis. Treatment with the least invasive method, either by minimal access techniques, non-invasive radiological procedures or medical treatment should be encouraged.

The Bologna Process and health science education: times are changing

CONTEXT

The Bologna Declaration of 1999 has led to the initiation of profound changes within the European Higher Education Area.

METHODS

This paper gives an overview of the Bologna Process, reviews the developments within European dental education that have arisen as a result of the Process, and describes the impact of the continuation of the Process on health science education in the UK.

CONCLUSIONS

The Bologna Process has led to the establishment of the European Higher Education Area, which is committed to implementing a series of action lines by 2010. Currently, we are just over halfway to 2010, and the importance of UK higher education institutions engaging with the Bologna Process is stressed.

The effect of a community dental service outreach programme on the confidence of undergraduate students to treat children: a pilot study

OBJECTIVE

To examine the effect of a community dental service (CDS) outreach teaching programme on undergraduates' confidence to undertake a range of paediatric dental procedures.

METHOD

Eighteen final year dental students completed a questionnaire prior to, and following participation in an outreach teaching programme. At each time point, the students were asked to identify how confident they felt to carry out a range of procedures commonly encountered in the treatment of children, employing a Likert scale modified to comprise six points where a rating of 1 represented 'not at all confident' and a rating of 6 'very confident'.

RESULTS

The distribution of scores at each time point indicated that students were more confident to carry out each of the listed procedures following participation in the outreach teaching programme than they had been on completion of their paediatric dentistry sessions within the School of Dentistry. At the individual student level, 16 of the 18 students indicated that they were, overall, more confident following their placement than previously.

CONCLUSIONS

It can be concluded that the long-established CDS outreach teaching programme run by the School of Dentistry, Wales College of Medicine in conjunction with the staff of Cardiff and Vale NHS Trust is a valuable adjunct to undergraduate teaching in paediatric dentistry.

Fragile Histidine Triad Expression in Oral Squamous Cell Carcinoma and Precursor Lesions

PURPOSE

Fragile histidine triad (FHIT) expression in precursor oral lesions (POL) and oral squamous cell carcinomas (OSCC) was studied with regard to (a) the frequency of loss of FHIT expression, (b) whether loss of FHIT expression correlates with degree of dysplasia in POLs, (c) whether FHIT loss predicts high-risk POLs that are more likely to transform, and (d) whether FHIT loss in OSCCs correlates with survival.

EXPERIMENTAL DESIGN

Ninety-four POLs and 86 OSCCs were immunostained for FHIT. Survival analysis was done for cases with validated clinical outcomes.

RESULTS

By optimizing the immunostaining protocol, we found that FHIT is expressed in a distinctive strong nuclear and weak cytoplasmic pattern in oral tissues. Loss of FHIT expression was found in 42 of 94 (45%) POLs and in 66 of 86 (77%) OSCCs. We observed a statistically significant positive correlation between frequency of FHIT loss and increasing grade of dysplasia (chi2=13.8; degrees of freedom=4; P=0.008). Loss of FHIT expression in POLs that progressed to malignancy was more frequent than in those that did not [17 of 25 (68%) versus 12 of 29 (41.4%), respectively]. This difference was statistically significant (chi2=3.8; degrees of freedom=1; P=0.046). In OSCCs, loss of FHIT staining indicated a worse prognosis (survival rate, 36.2%) than when positive FHIT staining was observed (survival rate, 50%), but the difference was not statistically significant (P=0.546, Kaplan-Meier, log-rank).

CONCLUSIONS

FHIT seems to localize to both nuclear and cytoplasmic domains. FHIT inactivation occurs early in oral carcinogenesis and may be useful molecular marker for progressive dysplastic oral lesions.

Self-treatment using a power drill: a case report

The intense pain of dental origin which patients suffer can be underestimated. This can lead them to self-harm or carry out self-treatment, sometimes with only the rudiments of how to achieve pain relief. A case is reported of a patient who attempted to relieve the intense pressure of an abscess arising in a maxillary cyst by using a home power drill. He drilled through the side of the tooth and drained the abscess but, unfortunately, fractured the drill. This was discovered at operation and meant the tooth had to be extracted. The patient had only received antibiotics prior to this for his abscess, with no drainage being undertaken.

CLINICAL RELEVANCE

This case highlights the inappropriate use of antibiotics when drainage of an abscess is the correct treatment. It demonstrates the extreme measures some patients may take in order to relieve their symptoms by self-treating themselves physically, in addition to self-prescribed medication.

Common facial fractures: 3. Complications

The final article of three, this paper highlights the complications that may arise either as a direct result of the fracture or the treatment of the fracture.

CLINICAL RELEVANCE

Dentists may encounter and sometimes have to manage some of the complications of facial fractures or their treatment.

Common facial fractures: 2. management

This, the second of three articles, highlights the management of facial fractures and the GDP's role in this.

CLINICAL RELEVANCE

For patients who present to dental practice with facial fractures, it is important that the dentist is able to inform the patient of his/her likely management in hospital.

Undergraduate clinical orthodontic experience: a discussion paper

Undergraduate clinical orthodontic experience may be expressed in a variety of ways. The most common way (used, inter alia, in the DentEd school visits) is by number of curriculum hours. Other ways include the number of patients seen, or number of procedures carried out. Whilst any of these methods may allow comparison between cohorts of students within a school or between schools, none of them are suitable to determine how much experience is 'satisfactory', nor do they indicate what the student should know, understand, or be able to do, to be considered 'satisfactory', and hence fit to graduate. This situation may be addressed by the use of competences and/or learning outcomes, and in 2004 the Association for Dental Education in Europe (ADEE) adopted a document that contained one major competence and five supporting competences in orthodontics. This paper considers the shortcomings of conventional methods of recording orthodontic experience in relation to the acquisition of these competences, and some ways in which staff and students may assess competence.

Differences in syntenic complexity between Medicago truncatula with Lens culinaris and Lupinus albus

Orthologous markers transferable between distantly related legume species allow for the rapid generation of genetic maps in species where there is little pre-existing genomic or EST information. We are using the model legume Medicago truncatula Gaertn. to develop such markers in legumes of importance to Australian agriculture. This will enable the construction of comparative genetic maps, help to determine patterns of chromosomal evolution in the legume family, and characterise syntenic relationships between M. truncatula and cultivated legumes. This information can then be used to identify markers that are tightly linked to the genes of interest, candidate gene(s) for a trait, and expedite the isolation of such genes. Among the Papilionoideae, we compared ESTs from the phylogenetically distant species, M. truncatula, Lupinus albus and Glycine max, to produce 500 intron-targeted amplified polymorphic markers (ITAPs). In addition to 126 M. truncatula cross-species markers from Department of Plant Pathology, University of California (USA), these markers were used to generate comparative genetic maps of lentil (Lens culinaris Medik.) and white lupin (Lupinus albus Linn.). Our results showed that 90% of the ITAPs markers amplified genomic DNA in M. truncatula, 80% in Lupinus albus, and 70% in Lens culinaris. The comparative map of Lens culinaris was constructed based on 79 ITAP markers. The Lupinus albus comparative map was developed from 105 gene-based markers together with 223 AFLP markers. Although a direct and simple syntenic relationship was observed between M. truncatula and Lens culinaris genomes, there is evidence of moderate chromosomal rearrangement. This may account for the different chromosome numbers in the two species. A more complicated pattern among homologous blocks was apparent between the Lupinus albus and M. truncatula genomes.

Common facial fractures: 1. Aetiology and presentation

Fractures of the facial bones are common and, in the West, usually occur as a result of interpersonal violence. Patients may attend dentists in the first instance as derangement of occlusion and other oral symptoms are common.

CLINICAL RELEVANCE

As patients with facial bone fractures may attend their dentist in the first instance, dentists should be confident in recognizing the signs and symptoms of facial fractures.

22 year phase 1/2 study of single agent carboplatin in metastatic seminoma: Potential for acceleration by a new surrogate end point, 72 hr PET scan response?

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Background: That metastatic seminoma may be more chemo-curable than non-seminoma was first suggested by Samuels (1980 Proc ASCO 21 abst 415) 4 of 5 patients durable CR to single agent cisplatin and by Oliver (1984 Proc ASCO 3. Abst 636) 9 of 10 durable responses. Carboplatin proved less effective and in randomised trials involving 361 patients relapse free survival was 72% with Carbo and 92% with cisplatin-based combination. Prompted by successful dose escalation of carboplatin in ovarian cancer, the initial phase 1 study that preceded the UK randomised trial was reopened and dosage escalated to AUC 8 and then 10. This abstract updates this study and provides more prolonged follow up of the previous reported cases. Methods: Initially patients received Carboplatin 450 mg/m2 (1983–7) and then AUC 7 (88–94), 8 (95–6) and 10 (97–06). The treatment was repeated q21 when possible and if delayed because of toxicity blood counts were repeated every 24 hours. Results: 60 metastatic seminoma patients have been treated between 1983 and 2006. 79%/95% of 19 receiving 450 mg/m2, 88%/94% of 17 receiving AUC 7 or 8 and 92%/100% of 24 receiving AUC 10 are progression free/alive. Overall 58 (97%) are alive and with 28 patients followed more than 10 years there have been no relapses after 26 months. Mild and rapidly recovering (med 14 d) transaminitis in 64% of AUC × 10 (med 93 range 51–541) suggests this may be the upper limit for safe use. As a pilot study 5 seminomas receiving AUC × 10 and 6 non-seminomas receiving BEP had PET scan before and at 72 hours after treatment. The only patient failing to respond substantially was a seminoma who showed increased PET activity on AUC × 10 but achieved complete remission of PET activity after one course of BEP. Conclusion: This data confirms the need for more studies of single agent platinum analogues in seminomas and reinforces the view that it may be preferable to radiotherapy for patients electing adjuvant treatment. With increasing attention being paid to late events, minimizing treatment toxicity and finding a fast track approach to proving safety is an increasing need. The data presented demonstrates the potential of early PET scan as a surrogate for response and could have accelerated the phase 1/2 study reported.

No significant financial relationships to disclose.

The familial influence on bilateral testicular germ cell cancer: Medical Research Council study TER2

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Background: There is evidence that hereditary predisposition is important in the aetiology of testicular cancer but the mode of inheritance is unknown. Methods: To test the hypothesis that bilateral disease (5% of testis cancer) is a manifestation of hereditary predisposition, a family questionnaire was sent to patients with bilateral disease (cases) and responses compared with institutional controls with unilateral disease (two approached for every case), matched for year of first diagnosis. The primary outcome measure was the risk of testis cancer in the brothers of cases and controls, and a relative risk of between 4.1 and 5.0 was anticipated based on the model of Nicholson and Harland (BJC 1995 71:421–426). Results: Responses from 191 cases and 373 controls have been analysed. No evidence of reduced fertility was found in the parents or grandparents of cases compared to those of controls. Cases (48%) were less likely to have children than controls (64%). The mean (SD) age of onset of testicular cancer was lower in cases (31 (9)) than controls (35 (9)), p < 0.001. The incidence of testis cancer in the relatives of cases and controls are shown in the table . Conclusions: The 4.6-fold greater risk to brothers of cases confirms the role of a familial predisposition in bilateral testicular cancer. Given the incomplete ascertainment for brothers, there is likely to be a greater risk to brothers than fathers. No major effect of an X-linked gene is found. These findings are in keeping with previously described hereditary models for testicular cancer.

[Table: see text]

No significant financial relationships to disclose.

Rapid measurement of blood propofol levels: a proof of concept study

OBJECTIVE

Despite many advantages over traditional volatile anaesthetic techniques, propofol total intravenous anaesthesia (TIVA) makes up a small percentage of general anaesthetics administered. One of the reasons for this is the absence of a clinically useful method for measuring blood propofol concentrations. We have designed and tested a prototype system for rapidly measuring blood plasma levels of propofol using solid phase extraction (SPE) methodology, coupled with colorimetric and spectrometric techniques.

METHODS

Multiple venous blood samples were taken from 17 subjects during induction of anaesthesia with propofol. Samples were analysed in duplicate on both the prototype system and using High Performance Liquid Chromatography (HPLC). The prototype monitor response was calibrated against known methanol-based propofol standards and an estimate of the plasma concentration of propofol derived from regression analysis of the standard responses.

RESULTS

Bland Altman analysis from a total of 87 samples gave 95% limits of agreement between the two methods of -0.34 to 0.42 microg mL(-1) (with no significant bias). The mean absolute prediction error was 8.9(7.5)%. The run time per sample on the prototype system was 4.5 min, including sample preparation.

CONCLUSION

The results show that this methodology may be suitable for rapid and accurate clinical monitoring of propofol levels during general anaesthesia.

Ovarian malignant melanoma: Unusual presentation of a solitary metastasis

BACKGROUND

Malignant melanomas of the ovary are rare with unpredictable clinical and biological behavior. We present this case report of a metastatic ovarian malignant melanoma, where the ovary was the first site of relapse after 10 years of remission.

CASE

A 58-year-old postmenopausal woman was incidentally found to have an abdominal mass, 10 years after removal of a cutaneous malignant melanoma lesion. Ultrasound and CT scan revealed an adnexal mass, which was found to be a solitary ovarian tumor at laparotomy. Histology confirmed malignant melanoma metastasis.

CONCLUSION

Relapse after a prolonged period of remission, presenting, as an isolated ovarian metastasis is an unusual presentation of malignant melanoma. As illustrated by this case report, a differential diagnosis of a metastatic malignant melanoma must be considered.

Influence of bulking agents and microbial activator on thermophilic aerobic transformation of sewage sludge

Bangkok, while improving the wastewater treatment in order to alleviate the river pollution, faces important amounts of sewage sludge. The sewage sludge contains organic matter, nitrogen and phosphorus available for plant growth. However, it may contain pathogenic microorganisms. To be used for agricultural purposes, these pathogens should be destroyed, which can be achieved with the thermophilic phase of composting. As the sewage sludge is dense and unable to compost alone (low C/N ratio), it should be mixed with an organic by-product. Two by-products available in large quantities in Thailand (wood chips and rice husk) have been tested for mixture with sewage sludge. As these products are not easy to decompose (presence of silica in rice husk and lignin/tannins in wood chips), the addition of a microbial activator for composting has been tested in controlled conditions (small quantities of organic mixtures, 55 degrees C, moisture maintained at 60-70% of water holding capacity). The monitoring of the decomposition has been made by measuring the carbon dioxide respiration, pH, organic matter and nitrogen contents and the evolution of enzymatic activities. When mixed with sewage sludge, wood chips and rice husk do not show significant differences concerning decomposition after 63 days. The use of an activator within the experimental conditions does not improve the decomposition of organic matter contained in the mixture of sewage sludge and rice husk or wood chips.

Port site ischemic necrosis: an unforeseen complication of laparoscopic surgery

A case of necrosis of the 10-mm umbilical port site after laparoscopic closure of enterocele in a 66-year-old woman is reported. Ischemic necrosis of the superficial tissue with cellulitis of the umbilical wound was seen during debridement. This highlights a hitherto unforeseen complication of laparoscopic surgery.