Community intervention for cardiovascular disease risk factors in Kalutara, Sri Lanka

BACKGROUND

The effectiveness of a 2015-17 community intervention to reduce cardiovascular disease (CVD) and type 2 diabetes (T2DM) risk factors is assessed in a Sri Lanka adult population, using a before-and-after study design.

METHODS

Four contiguous Public Health Midwife (PHM) areas in Kalutara district (Western Province) were exposed to a Sri Lankan designed community health promotion initiatives (without screening) to lower CVD and T2DM risk factors. Pre- and post-intervention surveys (2014, n=1,019; 2017, n=908) were of 25-64 year males (M) and females (F) from dissimilar randomly selected clusters (villages or settlements) from PHMs, with probability of selection proportional to population size, followed by household sampling, then individual selection to yield equal-probability samples. Differences in resting blood pressure (BP), fasting plasma glucose (FPG), total cholesterol, body mass index and tobacco smoking, adjusting for cluster sampling, age and socio-economic differences, were examined.

RESULTS

Hypertension prevalence declined from 25% to 16% (F) (p<.0001), and 21% to 17% (M). Both mean systolic and diastolic BP declined. T2DM declined from 18% to 13% (F), and 18% to 15% (M), as did mean fasting plasma glucose. Elevated total cholesterol declined from 21% to 15% in women (p=0.003) and mean cholesterol declined. Frequency distributions, medians and means of these continuous CVD risk factors shifted to lower levels, and were mostly statistically significant (p< 0.05).

CONCLUSIONS

Community health promotion can lower key CVD and T2DM risk factors. Lowering tobacco consumption in males and obesity remain challenges in Sri Lanka.

Levels and trends of smokeless tobacco use among youth in countries of the World Health Organization South-East Asia Region

BACKGROUND

At least two rounds of the Global Youth Tobacco Survey (GYTS) have been completed in most of the countries in the World Health Organization South-East Asia region. Comparing findings from these two rounds provides trend data on smokeless tobacco (SLT) use for the first time.

METHODS

This study uses GYTS data from Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste during 2006-2013. GYTS is a nationally representative survey of 13-15-year-old students using a consistent and standard protocol. Current SLT use is defined as using any kind of SLT products, such as chewing betel quid or nonbetel quid or snuffing any other products orally or through the nasal route, during the 30 days preceding the survey. Prevalence and 95% confidence intervals were computed using SAS/SUDAAN software.

RESULTS

According to most recent GYTS data available in each country, the prevalence of current use of SLT among youth varied from 5.7% in Thailand to 23.2% in Bhutan; among boys, from 7.1% in Bangladesh to 27.2% in Bhutan; and among girls, from 3.7% in Bangladesh to 19.8% in Bhutan. Prevalence of SLT was reported significantly higher among boys than girls in Bhutan (boys 27.2%; girls 19.8%), India (boys 11.1%; girls 6.0%), Maldives (boys 9.2%; girls 2.9%), Myanmar (boys 15.2%; girls 4.0%), and Sri Lanka (boys 13.0%; girls 4.1%). Prevalence of current SLT use increased in Bhutan from 9.4% in 2009 to 23.2% in 2013, and in Nepal from 6.1% in 2007 to 16.2% in 2011.

CONCLUSION

The findings call for countries to implement corrective measures through strengthened policy and enforcement.

Tobacco use, exposure to second-hand smoke, and cessation training among the third-year medical and dental students in selected Member States of South-East Asia region: a trend analysis on data from the Global Health Professions Student Survey, 2005-2011

BACKGROUND

The Medical and Dental Global Health Professions Student Surveys (GHPSS) are surveys based in schools that collect self-administered data from students on the prevalence of tobacco use, exposure to second-hand smoke, and tobacco cessation training, among the third-year medical and dental students.

MATERIALS AND METHODS

Two rounds of medical and dental GHPSS have been conducted in Bangladesh, India, Myanmar, Nepal, Sri Lanka, and Thailand, among the third-year medical and dental students, between 2005 and 2006 and 2009 and 2011.

RESULTS

The prevalence of any tobacco use among third-year male and female medical students did not change in Bangladesh, India, and Nepal between 2005 and 2006 and 2009 and 2011; however, it reduced significantly among females in Myanmar (3.3% in 2006 to 1.8% in 2009) and in Sri Lanka (2.5% in 2006 to 0.6% in 2011). The prevalence of any tobacco use among third-year male dental students did not change in Bangladesh, India, Nepal, and Thailand between 2005 and 2006 and 2009 and 2011; however, in Myanmar, the prevalence increased significantly (35.6% in 2006 to 49.5% in 2009). Among the third-year female students, a significant increase in prevalence was noticed in Bangladesh (4.0% in 2005 to 22.2% in 2009) and Thailand (0.7% in 2006 to 2.1% in 2011). It remained unchanged in the other three countries. Prevalence of exposure to second-hand smoke (SHS) both at home and in public places, among medical students, decreased significantly in Myanmar and Sri Lanka between 2006 and 2009 and in 2011. Among dental students, the prevalence of SHS exposure at home reduced significantly in Bangladesh, India, and Myanmar, and in public places in India. However, there was an increase of SHS exposure among dental students in Nepal, both at home and in public places, between 2005 and 2011. Medical students in Myanmar, Nepal, and Sri Lanka reported a declining trend in schools, with a smoking ban policy in place, between 2005 and 2006 and 2009 and 2011, while proportions of dental students reported that schools with a smoking ban policy have increased significantly in Bangladesh and Myanmar. Ever receiving cessation training increased significantly among medical students in Sri Lanka only, whereas, among dental students, it increased in India, Nepal, and Thailand.

CONCLUSION

Trends of tobacco use and exposure to SHS among medical and dental students in most countries of the South-East Asia Region had changed only relatively between the two rounds of GHPSS (2005-2006 and 2009-2011). No significant improvement was observed in the trend in schools with a policy banning smoking in school buildings and clinics. Almost all countries in the SEA Region that participated in GHPSS showed no significant change in ever having received formal training on tobacco cessation among medical and dental students.

Effects of a pediatric emergency department febrile infant protocol on time to antibiotic therapy

The purpose of this study was to examine the effect of an Emergency Department (ED) protocol to reduce time to antibiotic administration in the febrile infant less than 3 months of age with a rectal temperature > or =38.0 degrees C. We conducted a before-after study of a febrile infant quality improvement initiative in an urban pediatric ED with approximately 35,000 patient visits per year. Records of infants less than 3 months of age presenting with a rectal temperature > or =38.0 degrees C, who underwent a full septic work-up (blood, urine, and cerebrospinal fluid studies, and possibly chest radiography), were identified by using daily ED logs. This review was performed in the month before and then 12 months after institution of the "Septic Infant Work-up Sheet" and a set of interventions (Febrile Infant Protocol) designed to streamline care of the febrile infant and to reduce the time to antibiotic administration. Data were analyzed by using the Kaplan-Meier survival estimate and the log-rank test. Patient demographic characteristics and severity of illness were similar across months; however, ED process of care was significantly changed. Initial analysis revealed a median time to antibiotics of 142 min. Subsequent analysis after implementation of the Febrile Infant Protocol revealed a median time to antibiotics of 105 min. This represents an overall time reduction of 25% from time of presentation to antibiotic administration. In conclusion, a guideline-based ED febrile infant protocol changed clinical practice and improved time to antibiotics.

Foster parents of medically fragile children can improve their BLS scores: results of a demonstration project

OBJECTIVES

1) To assess performance and comfort level with cardiopulmonary resuscitation (CPR), foreign body removal (FBR), and seizure management in foster parents of medically fragile children; 2) To determine if the parents' performance and comfort levels increase with an individual teaching session with a medical professional to review CPR and FBR.

METHODS

In this single cohort pilot study, 18 foster parents of medically fragile children were asked to rate their comfort level with pediatric CPR and FBR on a 5-point scale (1 = very uncomfortable, 5 = very comfortable). They then underwent five mock code scenarios and were evaluated using a 5-point scale (1 = poor performance, 5 = outstanding performance). A 6-month follow-up evaluation using similar scenarios was conducted.

RESULTS

At visit 1, the percentage of parents demonstrating adequate performance of CPR, FBR, and seizure management was: 1) CPR: infant (78%); child (78%); 2) Foreign body removal: age <1 year (17%); age >1 year (65%); 3) Seizures (94%). At visit 2, performance improved in all areas, especially FBR, where the percentage of parents demonstrating adequate performance increased to 71% for children <1 year and 82% for children >1 year. As measured by the 5-point scales, CPR and FBR performance and parent comfort level with CPR improved significantly (Wilcoxon signed-ranks test, P < 0.004), but parent comfort level with FBR did not (P = 0.12).

CONCLUSIONS

Based on this pilot study, foster parents of medically fragile children benefit from an individual teaching session by a medical professional. CPR instruction for this group of foster parents should include adequate review and assessment of foreign body removal procedures.

Intrathoracic petechiae in sudden infant death syndrome: relationship to face position when found

Previous studies have not addressed the relationship of intrathoracic petechiae (IP) to the position of the face when a caretaker finds a victim of sudden infant death syndrome (SIDS). The aims of this retrospective study were to determine (1) the rate of the facedown position in SIDS (not to be confused with the prone body position), (2) if the facedown position occurred more frequently among SIDS victims with intrathoracic petechiae than those without petechiae, and (3) if the facedown position occurred more frequently among cases with more severe petechial hemorrhage of the thymus. We selected 199 SIDS cases from the San Diego SIDS Research Project database and grouped them as IP-present and IP-absent. Each case was analyzed with regard to the face position when found unresponsive or dead. Among these 199 cases, 37% were found face-down, which represents 51% of the 142 cases found prone. The two groups were similar with respect to age, sex, and rate of premature birth. Thirty-nine percent (39%) of the IP-present group and 9% of the IP-absent group were found in the facedown position (P = 0.057; 95% confidence interval for the difference = 0.3%, 40%). Cases were also grouped by severity of thymic petechiae and analyzed regarding face position. Neither age nor the facedown position was associated with greater severity of thymic petechiae. The wide confidence interval yielded by our analysis of IP limits our ability to clarify the precise pathophysiologic role of external oronasal obstruction in SIDS. While it remains possible that a subset of SIDS cases occur as a result of external obstruction, we are unable to generalize its importance. Internal airway obstruction and rebreathing with terminal gasping, both of which have been documented in sudden infant death, remain other possible scenarios leading to the production of IP.

Neck extension and rotation in sudden infant death syndrome and other natural infant deaths

It has been hypothesized that some cases of sudden infant death syndrome (SIDS) are a result of neck extension and/or rotation that causes vertebral artery (VA) compression and brain stem ischemia. There is a paucity of relevant literature on this topic. Therefore, our aim was to compare neck rotation and extension in SIDS and other natural infant deaths. Cases of SIDS and other natural infant deaths within the San Diego SIDS Research Project database were analyzed retrospectively with respect to neck and body position as reported by the trained, experienced scene investigators and/or the caretakers who discovered the infants. Information was used from 246 SIDS cases and 56 cases of other natural deaths. Simultaneous neck extension and rotation was not reported in either group. When data regarding neutral/flexed/extended position and rotation of the neck were combined, no significant differences were found between the two groups (P = 0.94); 40% of the SIDS cases and 41% of the other natural death cases were found with the neck either extended or rotated (odds ratio [OR] 0.97, [reference group = neck either neutral or flexed, and not rotated], 95% confidence interval [CI] 0.45, 2.11). There were also no significant differences between the groups when neck rotation and neck extension were analyzed independent of one another. Neck rotation among cases found in the prone position was common and was not significantly different between the two groups (49% of 146 SIDS cases, 58% of 24 other natural death cases, P = 0.38, OR 0.68, 95% CI 0.28, 1.62). Neck rotation among infants found in the supine position occurred one-third as often in the SIDS group (9% of 33 cases) as in the other natural death group (29% of 14 cases); however, the difference was not significant (P = 0.17; OR 0.25, 95% CI 0.05, 1.31). Although our analysis does not exclude VA compression and brain stem ischemia in some cases of SIDS, we found no evidence to affirm its importance. This study demonstrates the importance of meticulous scene descriptions, including neck position.

Successful treatment of retrograde ejaculation with sperm recovered from bladder washings. A report of two cases

BACKGROUND

Retrograde ejaculation causes < 2% of male infertility but is the leading cause of aspermia. The incidence of retrograde ejaculation is increasing due to the aggressiveness of modern urologic cancer surgery and an increase in diabetes mellitus. Generally, the only adverse effect is on fertility. Various approaches have been proposed for treatment, ranging from insemination with sperm-rich urine obtained after masturbation to intracytoplasmic sperm injection (ICSI). We used a protocol involving bladder washing.

CASES

Case 1 involved a man with retrograde ejaculation secondary to a successful right orchiectomy and retroperitoneal lymph node dissection for stage B1 embryonal cell carcinoma. He was treated with bladder washing and intrauterine insemination. He fathered three children from six insemination cycles. Case 2 involved a man with idiopathic retrograde ejaculation and a wife with ovulatory dysfunction. He received treatment similar to that in case 1 and fathered one child from two insemination cycles.

CONCLUSION

Larger studies need to be done specifically comparing treatments. Our method resulted in four normal infants in two couples over eight total insemination cycles and, taken together with other results from the literature, seems a good choice for clinicians who are treating retrograde ejaculation for the first time. We agree with others who have recommended that in vitro fertilization/ICSI not be the first step for treating the usual couples with retrograde ejaculation.

Laparoscopic removal of a perforated intrauterine device from the perirectal fat

BACKGROUND

The intrauterine device (IUD) was a very common form of birth control in the United States. The most serious potential complication of IUD use is uterine perforation. Uterine perforation is common among women with "lost" IUDs and can cause severe morbidity and mortality and should be carefully managed. The recommended treatment is removal of the perforating IUD. This can usually be managed laparoscopically unless bowel perforation or other severe sepsis is present.

METHODS

An intra-abdominal IUD was removed laparoscopically from the perirectal fat of a 49-year-old woman who had been diagnosed over 20 years earlier with an "expelled" IUD.

CONCLUSIONS

It is important that the possibility of uterine perforation be considered in anyone who has had a diagnosis of an expelled IUD without actual confirmation that the IUD is no longer present in the body. In any woman who presents with pelvic pain and a history of a "lost" IUD, the surgeon should have a high index of suspicion and obtain radiological studies. It may be advisable to question women about possible IUD use when they present with pelvic pain of unknown origin.

The effect of valproic acid on blood loss in patients with cerebral palsy

Valproic acid (VPA) is used in the treatment of seizure disorders often present in patients with cerebral palsy. The charts of 114 patients with cerebral palsy were reviewed to evaluate the effect of VPA on blood loss during spine surgery. Forty-one patients had seizure disorders. Of these, 18 were taking VPA as monotherapy (group III) and the remaining 23 patients were taking other antiseizure medications, including two taking VPA (group II). There was a significant increase in the number of patients with abnormal bleeding times and a significant difference (p < 0.001) in blood loss (ml/kg) in patients taking VPA as monotherapy (38.6 ml/kg vs. 30.0 ml/kg). There was also increased blood-product administration postoperatively in the VPA monotherapy patients. Physicians should be aware of this potential association between VPA use and increased blood loss. The routine laboratory tests of complete blood count, prothrombin time, and partial thromboplastin time will not adequately screen for the platelet-mediated effects of VPA.

The role of traumatic experiences in the genesis of obsessive-compulsive disorder

This paper discusses the role of traumatic stress in the genesis of obsessive-compulsive disorder. While the early classical conditioning theory of the onset of obsessive-compulsive disorder has only limited empirical support, authorities have always recognised the role of stress in precipitating this disorder, and in triggering relapse in those who have been successfully treated. Here, clinical cases are cited that show a causal link between severe trauma and the onset of obsessive-compulsive disorder. The nature of the traumatic reaction and the possible mechanisms by which it leads to frank obsessive-compulsive disorder are discussed. The apparent links between this and posttraumatic stress disorder are also explored. Finally, implications for therapy are considered.

Thought-starting: a review of new developments

This paper discusses the work on thought-starting, a clinical technique developed by Durac, over many years. Much clinical work has taken place in using and further developing this approach, and some research has also been carried out. This paper attempts a review of these developments. A selective account of some of the major developments is given. The implications of these developments are also briefly discussed.

Engagement and outcome in the treatment of bulimia nervosa: first phase of a sequential design comparing motivation enhancement therapy and cognitive behavioural therapy

Despite the major advances in the development of treatments for bulimia nervosa, drop-outs and a lack of engagement in treatment, continue to be problems. Recent studies suggest that the transtheoretical model of change may be applicable to bulimia nervosa. The aim of this study was to examine the roles of readiness to change and therapeutic alliance in determining engagement and outcome in the first phase of treatment. One hundred and twenty five consecutive female patients meeting DSM-IV criteria for bulimia nervosa took part in a randomised controlled treatment trial. The first phase of the sequential treatment compared four sessions of either cognitive behavioural therapy (CBT) or motivational enhancement therapy (MET) in engaging patients in treatment and reducing symptoms. Patients in the action stage showed greater improvement in symptoms of binge eating than did patients in the contemplation stage. Higher pretreatment scores on action were also related to the development of a better therapeutic alliance (as perceived by patients) after four weeks. However, pretreatment stage of change did not predict who dropped out of treatment. There were no differences between MET and CBT in terms of reducing bulimic symptoms or in terms of developing a therapeutic alliance or increasing readiness to change. The results suggest that the transtheoretical model of change may have some validity in the treatment of bulimia nervosa although current measures of readiness to change may require modification. Overall, readiness to change is more strongly related to improvement and the development of a therapeutic alliance than the specific type of treatment.

Impact of lifestyle choices on female infertility

OBJECTIVE

To inform physicians who are involved in the primary care of reproductive-age women of the specific relationships between lifestyle choices and infertility so that they can use this knowledge to educate their patients and encourage changes in behavior.

STUDY DESIGN

A review of the relevant literature, performed via Medline search.

RESULTS

Prevention of chlamydial and gonorrheal infections; maintenance of the proper body weight; increased individual awareness about the effects of age on fecundity; and reduced intake of caffeine, tobacco and alcohol are all possible avenues for primary prevention of infertility.

CONCLUSION

Lifestyle choices can be made that influence the reproductive capability of women. It may be worthwhile for primary care physicians to use information on lifestyle to encourage their patients to improve their overall health while positively affecting their ability to reproduce.

Gamete intrafallopian transfer. A cost-effective alternative to donor oocyte in vitro fertilization in women aged 40-42 years

OBJECTIVE

To investigate whether gamete intrafallopian transfer (GIFT) may be a cost-effective alternative to donor oocyte procedures in women 40 and older with good ovarian reserve.

STUDY DESIGN

Retrospective review of records at an infertility clinic in a large multispecialty group practice. Twenty two consecutive women aged 40 and older underwent 24 stimulation cycles for laparoscopic GIFT procedures from 1988 to 1997.

RESULTS

The mean GIFT cycle cost was $5,731. The delivery rate per stimulation cycle was 25.0%. The patients who gave birth were 40-42 years of age. The mean cost per delivered infant was $22,924. A previously reported value for mean cost per pregnancy for donor oocyte in vitro fertilization (IVF) was $30,457. Theoretical costs per delivery, generated from Society for Assisted Reproductive Technology outcome data for anonymous donor oocyte IVF in 1994 (delivery rate per transfer, 34.4%) for $8,000, $9,000 and $10,000 cycle costs were $23,256, $26,163 and $29,070, respectively.

CONCLUSION

In women with good ovarian reserve, GIFT may be a cost-effective alternative to donor oocyte IVF at age 40-42.

Ice-cream truck-related injuries to children

Few studies exist on the cause and nature of injuries to children from ice-cream truck-related accidents. We reviewed the medical records of 11 children with orthopedic injuries treated at Children's Hospital-San Diego from 1985 to 1995 for injuries in such accidents. Of nine children on their way to or from an ice-cream truck who were struck by an oncoming vehicle, all were girls; eight had pelvic or lower-extremity fractures. When ice-cream trucks park on the street, they pose a danger to children, because children are drawn to them, and the trucks' large size blocks the vision of oncoming drivers.

Etiology of supracondylar humerus fractures

The specific etiology of supracondylar humerus fractures in children is not well known. All supracondylar humerus fractures treated at Children's Hospital and Health Center, San Diego (CHSD) over an 8-year period (n = 391) were reviewed to determine specific information about the manner in which the injury occurred. Girls tended to sustain these fractures more often, and the nondominant arm was more often injured. Falls from a height accounted for 70% of the fractures. Children < or = 3 years old tended to fall off of household objects (beds, couches, other objects 3-6 feet high), and children 4 years and older tended to fall from playground equipment such as monkey bars, slides, and swings. Safety precautions should be implemented in homes of young children and at playgrounds to avoid these fractures.

Laparoscopic removal of virilizing hilar cell tumor in a postmenopausal patient

A postmenopausal woman experienced rapidly progressing hirsutism and signs of virilization. Hormone evaluations showed markedly elevated serum testosterone levels and no evidence of excess cortisol or dehydroepiandrosterone sulfate production. A computerized tomographic scan of the adrenals and ovaries was normal, and transvaginal ultrasound revealed a left ovary with a maximum diameter of 3.2 cm. At outpatient laparoscopic bilateral oophorectomy, the left ovary had a benign, 2.5-cm Leydig cell tumor, hilar cell variant. Laparoscopy may be useful in the diagnosis and treatment of select cases of virilizing tumors of the ovary.

Improving the cost-to-benefit ratio of in-vitro fertilization

In-vitro fertilization (IVF) has been criticized for being too costly to permit ready access to needy patients, either through their own funds or through those of third party providers. European groups have managed to offer these procedures at a fraction of the cost incurred by their United States counterparts by streamlining their protocols. Accordingly, we present our methods for reducing the cost of IVF. The main modification was made by performing the IVF procedures in the clinic under i.m. analgesia, avoiding the costs of a surgery suite and anaesthesia. In addition, donor, oocyte, micromanipulation, and cryopreservation services were not offered, reducing overall personnel and equipment costs. Overall costs were reduced from customary levels of $7,000--$11,000 in the United States to $3,409 per cycle initiated, while maintaining good ongoing/delivered pregnancy rates (30.0% versus 18.6% nationally) per cycle reaching aspiration. We conclude that, through the elimination of less necessary and/or utilized procedures, IVF may be performed in a more cost-effective manner while maintaining good success rates. For the patients who desire IVF services not offered under such a system, referral to a more specialized IVF center is appropriate.

High-frequency pressure-control ventilation with high positive end-expiratory pressure in children with acute respiratory distress syndrome

OBJECTIVE

Animal models suggest that high-frequency ventilation with low tidal volumes and high positive end-expiratory pressure (PEEP) minimize secondary injury to the lung. We hypothesized that using a high-frequency pressure-control mode of ventilation with high PEEP in children with severe acute respiratory distress syndrome (ARDS) would be associated with improved survival.

DESIGN

The study was a retrospective and prospective clinical study at a 24-bed tertiary care pediatric critical care unit. Fifty-three patients with severe ARDS were studied during a 37-month period, 30 prospectively and 23 retrospectively. Severe ARDS was defined as (1) rapid onset of severe bilateral infiltrates of noncardiac origin, (2) partial pressure of oxygen (arterial)/fraction of inspired oxygen less than 200 on PEEP of 6 cm H2O or more for 24 hours or longer, and (3) Murray disease severity score greater than 2.5. All patients meeting these criteria underwent ventilation in the pressure-control mode; the protocol for ventilation had the following general guidelines: (1) fraction of inspired oxygen limited to 0.5, (2) mean airway pressure titrated with PEEP to maintain arterial partial pressure of oxygen of 55 mm Hg or greater (7.3 kPa), (3) peak inspiratory pressure minimized to allow hypercapnia (arterial partial pressure of carbon dioxide, 45 to 60 mm Hg (6.0 to 8.0 kPa), and (4) ventilator rates of 40 to 120/min. Percutaneous thoracostomy and mediastinal tubes were placed for treatment of air leak.

RESULTS

The survival rate was 89% (47/53) in children with severe ARDS. Nonsurvivors had significantly higher peak inspiratory pressures (75 vs 40 cm H2O, p = 0.0006), PEEP (23 vs 17 cm H2O, p = 0.0004), mean airway pressure (40 vs 28 cm H2O, p = 0.04), alveolar-arterial oxygen gradient (579 vs 540 mm Hg, p = 0.03), and oxygenation index (43 vs 19, p = 0.0008) than survivors. Air leak was present in 51% of patients; there was no difference in the incidence of air leak between survivors and nonsurvivors (p = 0.42).

CONCLUSIONS

The high-frequency positive-pressure mode of ventilation was safe and was associated with an improved survival rate (89%) for children with severe ARDS. Limitation of both inspired oxygen and tidal volume, along with aggressive treatment of air leak, may have contributed to the improved survival rate.

Outpatient minilaparotomy ovarian cystectomy for benign teratomas in teenagers

Benign cystic teratomas are the most common ovarian neoplasms in adolescents. An ovary-conserving method was developed for outpatient surgical removal of benign cystic teratomas by minilaparotomy in teenagers. The technique requires no specialized training, laser devices, or expensive disposable instrumentation. As a precaution, the first teenager in whom the technique was used was observed as an inpatient for 3 days. Following this, the method was used as an outpatient procedure in three further cases. No complications occurred in any of the four patients, and the mean operating time of 85 minutes (range, 60 to 95 minutes) was similar to the reported time for removal of benign cystic teratomas by laparotomy. Although a randomized controlled study with many more patients would be necessary for a definitive conclusion, considerable cost savings and reduction in morbidity over traditional laparotomy are suggested by this experience.

Laparoscopic diagnosis and treatment of an infarcted epiploic appendage

A patient experienced acute abdominal pain that was diagnosed at laparoscopy as being due to an infarcted epiploic appendage. To our knowledge, this is the second report of laparoscopic diagnosis and treatment of an epipolic disorder. Infarcted epiploic appendages may be associated with bowel obstruction and abscess formation. Therefore, they should be looked for at the time of diagnostic laparoscopy for acute abdominal pain of unclear etiology, and removed if present.

Peripheral joint laxity increases in pregnancy but does not correlate with serum relaxin levels

OBJECTIVE

Our purpose was to evaluate peripheral joint laxity during pregnancy and to determine whether serum relaxin levels are associated with increased joint laxity.

STUDY DESIGN

A prospective observational study was performed.

RESULTS

A significant increase in joint laxity was found in five of seven peripheral joints over the course of the pregnancy and post partum. There was no correlation with serum relaxin levels. There were no significant differences in joint laxity on the basis of parity, age, or prepregnancy exercise levels.

CONCLUSIONS

Peripheral joint laxity is noted to increase as pregnancy progresses. The cause of this change is undetermined.

Equal effectiveness of electrical and volitional strength training for quadriceps femoris muscles after anterior cruciate ligament surgery

Neuromuscular electrical stimulation and voluntary muscle contraction are two exercise modes widely used in rehabilitation to strengthen skeletal muscle. Since there is no debate as to which mode is most effective, we compared electrical stimulation with voluntary contraction performed at matched intensities following reconstructive surgery of the anterior cruciate ligament. Forty men and women, aged 15-44, were randomly assigned to either an electrical stimulation or a voluntary contraction group. None of the subjects had a previous history of neuromuscular injury. The subjects received treatment for 30 minutes a day, 5 days a week, for 4 weeks. Knee extension torque was monitored during treatment to try to match the absolute muscular tensions (quantified as "activity") achieved during therapy. To match the activity of the subjects in the electrical stimulation group, who were treated at the highest stimulation intensity they could tolerate, the subjects in the voluntary contraction group were paced at progressively increasing intensities corresponding to 15, 25, 35, and 45% of the injured limb's maximum voluntary torque during weeks 1, 2, 3, and 4, respectively. We found no significant difference between the groups in terms of maximum voluntary knee extension torque throughout the study period. In addition, 1 year after surgery, there was still no significant difference between groups with regard to knee extension torque (p > 0.4). These data suggest that neuromuscular electrical stimulation and voluntary muscle contraction treatments, when performed at the same intensity, are equally effective in strengthening skeletal muscle that has been weakened by surgical repair of the anterior cruciate ligament.

Factors associated with improving success rates with gamete intrafallopian transfer under thin-needle spinal anesthesia

PURPOSE

In order to reduce the risk of major anesthetic complications associated with laparoscopic gamete intrafallopian transfer procedures, we have exclusively used thin-needle spinal anesthesia over the years 1991 - 1994. This paper will review complication rates in order to further establish the safety profile of GIFT under thin-needle anesthesia and report the changes in our GIFT protocol from 1991 to 1994 which have been associated with a statistical improvement in the implantation rate from 11% to 23% (P = 0.01) and an increase in delivery rates from 29% to 42% per transfer procedure.

METHODS

Sixty-eight laparoscopic GIFT procedures were done in women with at least one patent oviduct and failure to respond to less invasive treatment. Clinical variables were analyzed to determine if similar patient populations had been treated over the study period.

RESULTS

The improved delivery rates and implantation rates could not be explained by patient selection. No major perioperative complications occurred. Minor perioperative complications and difficulties included one patient requiring general anesthesia, one patient developing a spinal headache which could be managed conservatively at home, and one patient requiring a minilaparotomy to complete the GIFT procedure. The more serious complications occurred as a result of the superovulation and multiple oocyte transfer rather than the surgical or anesthetic technique. These included two patients with severe ovarian hyperstimulation requiring hospitalization, and five delivered triplet pregnancies. Factors associated with improving success rates included improvements in semen and equipment preparation as well as an increase in the number of sperm transferred from 200,000 to 500,000.

CONCLUSIONS

GIFT can be performed with relative safety under thin needle spinal anesthesia with high implantation and delivery rates if care is made to optimize sperm and equipment preparation. GIFT under thin-needle spinal anesthesia may be an attractive alternative for treatment of longstanding nontubal infertility in couples willing to take the risk of ovarian hyperstimulation and multiple pregnancy.

Improved combined laparoscopic and minilaparotomy technique to allow for reversal of extensive tubal sterilization

We assessed the efficacy of combined laparoscopic and minilaparotomy for outpatient microsurgical reversal of extensive tubal sterilization in 11 women undergoing the procedure and followed for a mean of 24.7 months. All patients desired reversal of extensive tubal sterilization, and had 4 cm or less of the longer oviduct remaining. The mean operating time was 110 minutes, and the mean total cost was $5067. There were no major complications. Two women were treated for uncomplicated cystitis within 1 month of surgery. Five (45%) of 11 women delivered viable infants; one patient had two ectopic pregnancies. These preliminary data suggest that outpatient combined laparoscopy and minilaparotomy may be effective in patients who desire restoration of fertility after extensive tubal sterilization.

Post-traumatic stress disorder in airplane cabin crew attendants

Six cabin crew attendants who survived an airplane crash in which 47 passengers were killed were assessed for post-traumatic stress disorder and other psychological problems. Each was interviewed 8 months after the crash and completed questionnaires measuring intrusive thoughts, avoidance, depressed mood, anxiety, and fear. Questionnaires were repeated 10 months later. All six met DSM-III-R criteria for post-traumatic stress disorder, reported a wide range of symptoms, and developed a fear of flying 8 months after the crash. Depression scores were normal 18 months after the crash, but all other measures remained unchanged, showing a continued high level of traumatic stress. Results point to the potential for crash survivors to develop chronic psychological problems. The highest levels of distress were reported by the three most senior members of staff with the most responsibility on board, who had also suffered the most severe physical injury. Clinical implications of the results are discussed, and the need for predisaster training of cabin crew and postdisaster treatment is emphasized.

Serum parathyroid hormone-related protein levels during lactation

We measured parathyroid hormone-related protein (PTHrP) in the serum of 15 healthy women within three days of beginning breast-feeding and within one hour of completing nursing. A sensitive immunoradiometric assay that measures N-terminal PTHrP containing at least the first 74 amino acids was used. We found normal PTHrP values in all patients. Values one day before and two days after delivery in a hypoparathyroid woman who chose not to breast-feed were also normal. Since N-terminal PTHrP fragments of 1-36 amino acids or more are biologically active, we believe additional studies using sensitive PTHrP assays that measure smaller fragments and investigations performed under other conditions of breast-feeding are necessary before concluding that PTHrP does not have a role in calcium homeostasis in nursing mothers. Furthermore, additional studies in hypoparathyroid nursing mothers should be performed.

Laparoscopic treatment of heterotopic pregnancy

The increasing frequency of pelvic inflammatory disease and use of ovulation-induction agents has resulted in a corresponding increase in the frequency of heterotopic pregnancy. In most reported cases the diagnosis was made retrospectively at the time of laparotomy. With improvements in ultrasonography and operative laparoscopy, the diagnosis can be made preoperatively and the disease treated surgically with low morbidity. In a woman who had received clomiphene citrate for ovulation induction, the diagnosis of heterotopic pregnancy was suspected preoperatively based on transvaginal ultrasonography. The patient was treated laparoscopically by partial salpingectomy, and subsequently delivered a normal infant.

Spontaneously acquired, unilateral absence of the adnexa. A case report

A free-floating, calcified cyst was found in the peritoneal cavity in association with unilateral absence of the adnexa. The evidence was that it was due to torsion and separation of the adnexa from their supporting structures. This phenomenon may be a cause of congenital absence of the ovary.

The 'match/mismatch' model of fear: empirical status and clinical implications

This paper reviews empirical evidence for the 'match/mismatch' model of fear and defines what is currently known about the prediction of fear. It also outlines several gaps in the literature on this topic and problems with the methodology used to study this phenomenon. Some of these gaps are filled by studies on the prediction of pain and where relevant these are discussed. Important areas for future research are identified, the clinical implications of the model are outlined and specific suggestions for treatment are made.

Use of the Edinburgh Postnatal Depression Scale to identify postpartum depression in a clinical setting

The Edinburgh Postnatal Depression Scale (EPDS) is a validated instrument developed specifically to identify women experiencing postpartum depression (PPD). This study sought to determine the extent of postpartum depression in our population and the maternal characteristics associated with it and to also determine if the scale increased practitioner awareness and treatment of PPD. Two hundred eighty-seven women from the total population completing the EPDS in 1991 (n = 1,139) were randomly selected for retrospective chart review to identify relationships between maternal characteristics and elevated EPDS scores. Charts were also reviewed for outcomes related to depression for the six-month period after delivery. Statistical analysis of the data revealed that 17.4% of the total population had an EPDS score of > or = 10, indicating a potential risk of developing PPD. Eight percent scored > or = 13, suggesting that further assessment was necessary. Marital instability, lack of medical insurance and a history of depression were the factors found to correlate most significantly with elevated EPDS scores. The physicians and midwives providing service for our population were interviewed, and 83% reported that the EPDS had increased their awareness of PPD, while 92% reported having referred for treatment patients with high EPDS scores. Use of the EPDS scale can improve practitioner awareness and aid in the diagnosis of PPD. Several easily identifiable variables are associated with PPD.