Progress with the regulation of radiation safety during recovery and removal of spent nuclear fuel from the site for temporary storage at Andreeva Bay on the Kola Peninsula

In the 1960s, a shore technical base (STB) was established at Andreeva Bay on the Kola Peninsula, in northwest Russia. The STB maintained nuclear submarines and the nuclear icebreaker fleet, receiving and storing fresh and spent nuclear fuel (SNF) as well as solid and liquid radioactive waste (RW). It was subsequently re-designated as a site for temporary storage (STS) for SNF and RW. Over time, the SNF storage facilities partly lost their containment functions, leading to radioactive contamination of workshops and the site above permitted values. The technological and engineering infrastructure at the site was also significantly degraded as well as the condition of the stored SNF. At present, the STS Andreeva Bay facility is under decommissioning. This paper describes progress with the creation of safe working measures for workers involved in site remediation and SNF recovery operations, including the determination of safe shift times in high radiation areas, as part of overall optimization of safety. Results are presented for the successful application of these measures in the period 2019-2021, during which time significant SNF recovery and removal operations were completed without incident. Significant important experience has been gained to support safe removal of remaining SNF, including the most hazardous degraded fuel, as well as recovery of other higher level RW and decommissioning of the old storage buildings and structures.

Transforming growth factor beta1 gene expression during vaginal wound healing in a rabbit menopause model

OBJECTIVE

Surgical outcome following reconstructive pelvic surgery is largely dependent on the vaginal wound healing process. As peri- and post-menopausal women are the most likely candidates to undergo these surgeries, it is important to understand the effect of estrogen deficiency on this process. Transforming growth factor beta (TGFβ) is an important mediator of wound healing. We sought to assess TGFβ1 gene expression during the vaginal incisional wound healing process in a rabbit menopause model.

DESIGN

Animal study.

SETTING

Animal laboratory.

SAMPLE

Sixty-three rabbits were used for this study.

METHODS

Twenty-one underwent bilateral oophorectomy, 21 underwent a sham surgery, and 21 served as controls. Eight weeks later, standardised full-thickness 6-mm diameter circular segments were excised from the vagina of all rabbits. Animals were killed sequentially, before wounding, and at 0, 4, 7, 14, 21 and 35 days after wounding, and the wounds were harvested.

MAIN OUTCOME MEASURES

Wound closure and TGFβ1 gene transcription, as measured by real-time polymerase chain reaction (PCR).

RESULTS

Wound closure was significantly protracted (P < 0.02), whereas TGFβ1 gene expression was significantly increased (P < 0.0001) during the wound healing process in oophorectomised rabbits, as compared with both control and sham groups.

CONCLUSION

Oophorectomised rabbits show protracted incisional vaginal wound healing associated with increased TGFβ1 gene transcription.

The kinetics of leptin in Meigs' syndrome

OBJECTIVE

The aim of this study was to assess the kinetics and possible role of leptin in the pathophysiology of Meigs' syndrome.

METHODS

We report on a 62-year-old patient admitted for a large ovarian tumor, hydrothorax, and ascites. The patient underwent abdominal hysterectomy and bilateral adnexectomy revealing a benign ovarian fibroma and no evidence of malignant cells in the pleural or peritoneal fluids. Analysis of serum, peritoneal, and pleural fluids from this patient was performed before, during, and after the operation.

RESULTS

Preoperatively, the patient had low levels of leptin in the serum, peritoneal, and pleural fluids. Serum levels increased after removal of the ovarian tumor along with the resolution of ascites and hydrothorax.

CONCLUSION

Leptin levels inversely correlate to tumor burden, third space fluid accumulation, and clinical status in Meigs' syndrome. These findings suggest the involvement of leptin in the pathophysiology of this syndrome.

Soluble ICAM-1 and E-selectin levels correlate with clinical and biological aspects of severe ovarian hyperstimulation syndrome

OBJECTIVE

To assess the potential involvement of the soluble endothelial cell-leukocyte adhesion molecules E-selectin and intercellular adhesion molecule-1 (ICAM-1) in the pathophysiology of capillary hyperpermeability in the ovarian hyperstimulation syndrome (OHSS).

DESIGN

Controlled clinical study.

SETTING

Women hospitalized for severe OHSS after ovulation induction for IVF at two tertiary medical centers.

PATIENT(S)

Eleven patients with severe OHSS undergoing IVF and 20 controls who had received a similar ovulation induction regimen and did not develop OHSS.

INTERVENTION(S)

Serial serum samples were obtained from all patients with OHSS from admission until discharge. Ascitic fluid was obtained from all patients by therapeutic paracentesis. Serum was obtained from all controls 4-8 days after ET.

MAIN OUTCOME MEASURE(S)

Samples were assayed for soluble E-selectin and soluble ICAM-1 by using enzyme-linked immunosorbent assay and results were correlated with clinical and biological aspects of OHSS.

RESULT(S)

Compared with controls, patients with severe OHSS had higher levels of soluble ICAM-1 and lower levels of soluble E-selectin detected in serum and ascites. Serum levels of soluble ICAM-1 decreased, while soluble E-selectin levels increased along with clinical and biological improvement. Serum soluble ICAM-1 showed significant positive correlation and serum soluble E-selectin showed significant negative correlation with clinical and biological aspects of severe OHSS.

CONCLUSION(S)

Soluble ICAM-1 and soluble E-selectin seem to be involved in the pathophysiology of capillary hyperpermeability in severe OHSS.

Hydroxyethylstarch versus human albumin for the treatment of severe ovarian hyperstimulation syndrome: a preliminary report

OBJECTIVE

To compare the efficacy and safety of 6% hydroxyethylstarch and human albumin as colloid solutions for treatment of severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

Controlled cohort study.

SETTING

Tertiary medical center.

PATIENT(S)

Sixteen patients with severe OHSS.

INTERVENTION(S)

Six percent hydroxyethylstarch (6 patients) and human albumin (10 patients).

MAIN OUTCOME MEASURE(S)

Urine output, number of abdominal and pleural drainage procedures, complications, duration of hospitalization, and perinatal outcome.

RESULT(S)

Patients who received 6% hydroxyethylstarch had higher urine output, needed fewer abdominal and pleural paracenteses, and had a shorter hospital stay than those who received human albumin. In each group, no adverse effects or congenital malformations were observed and the rates of miscarriage were similar.

CONCLUSION(S)

These results suggest that 6% hydroxyethylstarch may be superior to albumin as a colloid solution for the treatment of severe OHSS.

Markedly elevated levels of vascular endothelial growth factor, fibroblast growth factor, and interleukin 6 in Meigs syndrome

Analysis of serum and peritoneal and pleural fluid from a patient with Meigs' syndrome revealed high levels of vascular endothelial growth factor, fibroblast growth factor, and interleukin 6. Serum levels declined after removal of the ovarian tumor, along with resolution of ascites and hydrothorax. These findings suggest the involvement of these vasoactive factors in ascites and pleural fluid formation in Meigs' syndrome.

Indomethacin for preterm labor: a randomized comparison of vaginal and rectal-oral routes

OBJECTIVE

To compare the efficacy of intravaginal and intrarectal plus oral indomethacin for the treatment of preterm labor.

METHODS

Between December 1996 and November 1998, 46 eligible gravidas admitted with singleton pregnancies and idiopathic preterm labor before 33 gestational weeks were randomized to receive 200 mg of intravaginal or intrarectal plus oral indomethacin.

RESULTS

Twenty-three subjects were allocated to each study group. The interval from initiation of treatment to delivery was significantly longer in the intravaginal indomethacin group (26.5 +/- 5.7 versus 12.6 +/- 3.7 days; P =.007). Delivery was delayed by more than 7 days in 18 of 23 subjects (78%) in the intravaginal indomethacin group compared with ten (43%) in the intrarectal plus oral indomethacin group (P =.03). Birth weights were significantly higher (2306 +/- 436 versus 1862 +/- 232 g; P =.002) and hospitalization in a neonatal intensive care unit (NICU) (3.1 +/- 0.8 versus 9.3 +/- 3. 7 days; P =.001) and mechanical ventilation (1.4 +/- 0.2 versus 5.3 +/- 1.6 days; P =.001) were significantly shorter in the intravaginal indomethacin group.

CONCLUSION

Intravaginal indomethacin is more effective than intrarectal plus oral application in delaying preterm labor and is associated with higher birth weights, shorter NICU stays, and shorter intervals of mechanical ventilation.

Increased levels of basic fibroblast growth factor are found in the cross-clamped heart during cardiopulmonary bypass

BACKGROUND

High concentrations of fibroblast growth factors (FGFs) are found in the heart. Even higher levels are measured during ischemia. Exogenous administration of FGF to ischemic myocardium promotes synthesis of collateral coronary circulation and induces local myocardial hypertrophy. The kinetics and the contribution of the heart and lungs to circulating basic FGF (bFGF) levels during cardiac surgery were characterized.

PATIENTS AND METHODS

Plasma bFGF levels were measured in seven adults undergoing coronary artery bypass operations and 11 neonates undergoing congenital cardiac anomaly repair during cardiopulmonary bypass.

RESULTS

In both the adult and the neonatal groups, bFGF plasma levels increased significantly immediately after removal of the aortic cross-clamp (adult group 15.43+/-6.3 aorta cross-clamped versus 29+/-4.1 after release, P=0.011; neonatal group 17.09+/-9.43 aorta cross-clamped versus 43.55+/-14.25 after release, P=0.004) and declined thereafter. In the adult group, higher levels of bFGF were recorded in blood recovered from the coronary sinus than in the aortic root during aortic cross-clamping (63.14+/-14.42 versus 43.86+/-12.05, P=0.011), and in both, levels were significantly higher than the peripheral measurements.

CONCLUSIONS

Plasma bFGF levels increase during cardiopulmonary bypass. The source of this elevation is the lungs and heart.

Pulmonary manifestations of severe ovarian hyperstimulation syndrome: a multicenter study

OBJECTIVE

To assess the pulmonary manifestations of severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

A retrospective nationwide 10-year multicenter study.

SETTING

Sixteen of 19 tertiary medical centers in Israel.

PATIENT(S)

All patients hospitalized at these centers for severe OHSS between January 1987 and December 1996.

MAIN OUTCOME MEASURE(S)

Clinical presentation, arterial blood gases on room air, and chest roentgenogram results.

RESULT(S)

Of 209 patients, 4% had lobar pneumonia, 2% had adult respiratory distress syndrome (ARDS), and 2% had pulmonary thromboembolism. Most patients had dyspnea, tachypnea, moderate hypoxemia, increased alveolar-arterial oxygen difference, hypocarbia, respiratory alkalosis, and metabolic compensation. The most common findings on chest roentgenogram were bilateral elevation of the diaphragm, pleural effusion, and pulmonary atelectasis. Patients with pulmonary thromboembolism, ARDS, and pneumonia presented with severe hypoxemia and alveolar-arterial oxygen difference and distinct radiographic findings.

CONCLUSION(S)

Severe OHSS is characterized by an extraparenchymal restrictive type of pulmonary dysfunction, attributed to intraabdominal or pleural fluid accumulation, which limits descent of the diaphragm and expansion of the thoracic cage. This may induce uncoordinated lung ventilation and atelectasis with subsequent ventilation-perfusion mismatch and hypoxemia. The clinical picture may deteriorate further because of pulmonary infection, pulmonary thromboembolism, or ARDS, all of which have distinct clinical, radiographic, and blood gas characteristics.

Plasma immunoglobulins in patients with severe ovarian hyperstimulation syndrome

OBJECTIVE

To assess immunoglobulin (Ig) concentrations in plasma and ascitic fluid of patients with severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

Controlled clinical study.

SETTING

Tertiary medical center.

PATIENT(S)

Ten patients with severe OHSS after ovulation induction for IVF and 10 controls who had undergone similar ovulation induction and did not develop OHSS.

INTERVENTION(S)

Three blood samples were obtained from each OHSS patient: one at the time of hospitalization for severe OHSS, one when significant clinical improvement was evident, and one at the first follow-up visit after discharge from the hospital. Blood samples were drawn from control patients 6-8 days after ET. Ascitic fluid was obtained from all patients with OHSS by therapeutic paracentesis.

MAIN OUTCOME MEASURE(S)

Immunoglobulin concentrations were assayed by radial immunodiffusion.

RESULT(S)

Significantly lower levels of gamma-globulins, specifically IgG and IgA, were detected in the plasma of patients with severe OHSS, whereas alpha- and beta-globulin levels as well as IgM levels were not significantly different from those in controls. Both IgG and IgA levels increased as patients clinically improved. Ascitic fluid contained high IgG, moderate IgA, and negligible IgM levels.

CONCLUSION

Severe OHSS is characterized by hypogammaglobulinemia, attributed to leakage of medium-molecular-weight immunoglobulins such as IgG and IgA to the peritoneal cavity.

Obstetric outcome of in vitro fertilized pregnancies complicated by severe ovarian hyperstimulation syndrome: a multicenter study

OBJECTIVE

To assess the outcome of pregnancies conceived with the use of IVF that are complicated by severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

A retrospective nationwide multicenter study.

SETTING

Sixteen of 19 tertiary care medical centers in Israel.

PATIENT(S)

All patients undergoing IVF who were hospitalized for severe OHSS between January 1987 and December 1996.

MAIN OUTCOME MEASURE(S)

Pregnancy rate (PR) and rates of multiple gestation, miscarriage, ectopic pregnancy, obstetric complications, and intervention.

RESULT(S)

A total of 163 patients who had severe OHSS after IVF treatment were identified, of whom 142 (87.1%) had undergone ET. The clinical PR was 73.2%; 42.3% were singletons, 33.6% were twins, 17.3% were triplets, and 6.7% were quadruplets. The miscarriage rate was 29.8%, whereas the incidence of ectopic pregnancy was 1.9%. Forty-four percent of all births were premature, and 62.1% of all newborns had low birth weight. The most common antenatal complications were pregnancy-induced hypertension (13.2%), gestational diabetes (5.9%), and placental abruption (4.4%). The rate of cesarean section was 44.1%.

CONCLUSION(S)

Among patients who have severe OHSS after IVF treatment, the pregnancy rate and the rates of multiple gestation, miscarriage, prematurity, low birth weight, pregnancy-induced hypertension, gestational diabetes, and placental abruption are significantly higher than those reported previously for pregnancies conceived with the use of assisted reproductive techniques.

Febrile morbidity in severe and critical ovarian hyperstimulation syndrome: a multicentre study

The objective of this study was to define the incidence of febrile morbidity and its causes in severe and critical ovarian hyperstimulation syndrome (OHSS). For this purpose, we reviewed the medical records of all OHSS patients hospitalized in 16 out of 19 tertiary medical centres in Israel between January 1987 and December 1996. Febrile morbidity was defined as at least one episode of temperature rise above 38 degrees C lasting > or =24 h. A total of 2902 patients (3305 hospitalizations) with OHSS was identified, of whom 196 had severe, and 13 critical, OHSS. Among the 209 patients investigated the incidence of febrile morbidity was 82.3%, of which 20.5% was attributed to urinary tract infection, 3.8% to pneumonia, 3.3% to upper respiratory tract infection, 2.0% to intravenous line phlebitis, 1.0% to cellulitis at an abdominal puncture site, 1.0% to postoperative wound infections and 0.5 % to gluteal abscess at the site of progesterone injection. Non-typical organisms were frequently isolated, such as Pseudomonas, Proteus, Klebsiella and Enterobacter species. No infectious aetiology was found in 105 patients (50.2%). Hypoglobulinaemia was recorded in most patients, while ascitic and pleural fluids aspirated from these patients contained high globulin concentrations. We conclude that infection-related febrile morbidity in severe and critical OHSS is high, and may be attributed to some degree of immunodeficiency associated with loss of plasma globulins to the third space. However, non-infection-related febrile morbidity is even higher and may be attributed to endogenous pyrogenic mechanisms.

Castleman disease in pregnancy

BACKGROUND

Castleman disease, a rare disorder characterized by benign proliferation of lymphoid tissues, generally presents as a solitary mediastinal mass. We report the first case of this disease during pregnancy.

CASE

A 32-year-old woman presented with a large abdominal mass and vaginal bleeding during the second trimester of pregnancy. Abdominal ultrasound demonstrated a large, retroperitoneal solid mass of mixed echogenicity and increased vascularity. The patient underwent explorative laparotomy that revealed a mesenteric mass, histologically consistent with Castleman disease of the hyaline-vascular type. The mass was excised completely, and the immediate postoperative course was uneventful, although the patient went into spontaneous preterm labor during the 29th week of pregnancy.

CONCLUSION

Castleman disease should be considered one of the benign etiologies for an abdominal or retroperitoneal mass during pregnancy.

Doppler findings in chronic ectopic pregnancy: case report

Chronic ectopic pregnancy is an uncommon form of tubal pregnancy manifested as a pelvic mass with minimal symptoms and a low or absent titer of human chorionic gonadotropin. For this reason, most of the reported cases have been diagnosed only after explorative laparotomy. The value of Doppler ultrasonography for preoperative diagnosis of this entity has not yet been established. We report on a 36-year-old patient who was admitted for intermittent right lower quadrant abdominal pain of 3 months' duration, and a right adnexal mass found on pelvic examination. On Doppler ultrasonography, a right complex adnexal mass was demonstrated, characterized by extensive external vascularization, aberrant vessels and arteriovenous shunting, but with no internal blood flow. Explorative laparotomy revealed a right tubal mass adherent to the omentum, and covered by numerous enlarged and tortuous blood vessels originating in the omentum. Pathological examination of the mass revealed a chronic ectopic pregnancy. The possible contribution of Doppler-specific characteristics for the diagnosis of chronic ectopic pregnancy is described and discussed.

Vascular endothelial growth factor plasma levels correlate to the clinical picture in severe ovarian hyperstimulation syndrome

OBJECTIVE

To assess the potential involvement of vascular endothelial growth factor in the hyperpermeability characterizing the ovarian hyperstimulation syndrome (OHSS).

DESIGN

A controlled clinical study that followed the kinetics of vascular endothelial growth factor in the plasma of patients with severe OHSS from the time of admission to the hospital and until clinical resolution.

SETTING

Women hospitalized with severe OHSS in a tertiary medical center.

PATIENT(S)

Seven patients with severe OHSS after ovulation induction for IVF and seven controls who had received a similar ovulation induction regimen and did not develop the OHSS.

INTERVENTION(S)

Three blood samples were obtained from each OHSS patient: upon hospitalization for severe OHSS, when significant clinical improvement was evident, and on the first follow-up visit after the patients' discharge. Ascitic fluid was obtained from all OHSS patients by therapeutic paracentesis during the active phase of the syndrome. Blood samples were drawn from the control patients 4 to 6 days after ET. All samples were assayed for vascular endothelial growth factor levels, hematocrit, E2 levels, and white blood cell count.

MAIN OUTCOME MEASURE(S)

Vascular endothelial growth factor levels were assayed by ELISA. Estradiol was determined by RIA.

RESULT(S)

Compared with the controls, high levels of vascular endothelial growth factor were detected in the plasma of all patients admitted for severe OHSS. Levels dropped significantly along with clinical improvement, reaching minimum values after complete resolution. A statistically significant correlation was found between plasma vascular endothelial growth factor levels and certain biologic characteristics of OHSS and of capillary leakage such as leukocytosis and increased hematocrit. Ascitic fluid obtained from the study patients also contained high vascular endothelial growth factor levels.

CONCLUSION(S)

These findings suggest the involvement of vascular endothelial growth factor in the pathogenesis of capillary leakage in the OHSS.

Antibiotic prophylaxis in umbilical and incisional hernia repair: a prospective randomised study

OBJECTIVE

To find out if preoperative prophylaxis would reduce infection rates after umbilical and incisional hernia repair.

DESIGN

Randomised controlled trial.

SETTING

Teaching hospital, Israel.

SUBJECTS

35 Patients who presented with umbilical (n = 19) or incisional (n = 16) hernias during a period of 8 months.

INTERVENTIONS

Cefonicid 1 g was given by intravenous infusion to alternate patients 30 minutes before the operation.

MAIN OUTCOME MEASURES

Wound infection.

RESULTS

The groups were comparable for age, body mass index, grade of surgeon, operating time, and size of hernial ring. The wound infection rates were 0/8 compared with 4/8 for incisional hernia repairs (p = 0.08) and 1/9 compared with 4/10 for umbilical hernia repairs (p = 0.3). The overall rate was 1/17 compared with 8/18 (p = 0.02).

CONCLUSIONS

Single dose antibiotic puphylaxis seems to exert a beneficial effect on the wound infection rate after umbilical and incisional hernia repair.

Plasma inflammatory cytokines correlate to the ovarian hyperstimulation syndrome

The objective of this study was to follow the kinetics of four inflammatory cytokines in the plasma and ascitic fluid of seven patients who developed severe ovarian hyperstimulation syndrome (OHSS) after induction of ovulation for in-vitro fertilization. Blood samples were obtained from these patients at three different times: upon hospitalization; when significant clinical improvement was evident; and after complete resolution. Samples were analysed for interleukin-1 (IL-1), interleukin-6 (IL-6), interleukin-8 (IL-8) and tumour necrosis factor alpha (TNF-alpha). Ascitic fluid was obtained by therapeutic paracentesis from all study patients during the active phase and analysed for these cytokines. Two control groups were available: the first included 15 women undergoing controlled ovarian stimulation for in-vitro fertilization without developing OHSS, while the second consisted of 25 healthy women not undergoing ovulation induction or any other medical treatment. High concentrations of IL-1, IL-6 and TNF-alpha were detected in all individuals upon admission for severe OHSS. Concentrations dropped significantly along with clinical improvement, reaching normal values after complete resolution. A statistically significant correlation was found between plasma cytokine concentrations and certain biological characteristics of the syndrome such as leukocytosis, increased haematocrit, and elevated plasma 17-beta-oestradiol concentrations. Ascitic fluid obtained from the study patients contained high IL-6 and IL-8 concentrations, while other cytokines were unaltered. These results suggest close association between inflammatory cytokines and the pathophysiology of the ovarian hyperstimulation syndrome.

Characterization of intraperitoneal cytokines and nitrites in women with severe ovarian hyperstimulation syndrome

OBJECTIVE

To assess the potential involvement of cytokines and nitrites in the hyperpermeability characterizing the ovarian hyperstimulation syndrome (OHSS).

DESIGN

A controlled clinical study comparing peritoneal fluid (PF) from patients with severe OHSS and from non-OHSS controls.

SETTING

Women hospitalized with severe OHSS in three tertiary medical centers.

PATIENTS

Twelve patients with severe OHSS necessitating paracentesis and 20 non-OHSS controls.

INTERVENTIONS

The criteria for ultrasound-guided paracentesis were tense ascites, hydrothorax, hemoconcentration, or oliguria.

MAIN OUTCOME MEASURES

Interleukin (IL) 1 beta IL-1 receptor agonist, IL-2, IL-6, IL-8, and tumor necrosis factor alpha (TNF alpha) levels in PF were assayed by ELISA; nitrites were measured by the "Griess" reaction. Estradiol and P were determined by RIA.

RESULTS

Ovarian hyperstimulation syndrome patients had significantly higher PF IL-6 (3,523 versus 30 pg/mL), TNF alpha (14 versus 4.2 pg/mL), and IL-8 (1,695 versus 900 pg/mL). In the serum, only IL-6 levels were significantly higher (375 versus 11 pg/mL). Conversely, nitrite levels were significantly lower in PF of OHSS patients (0.5 versus 34 nmol/mL). Interleukin 1 levels were higher and IL-1 receptor antagonist levels were lower in OHSS patients, suggesting potentially increased biologic potency of IL-1.

CONCLUSION

These findings suggest that these substances could be involved in mediating the capillary hyperpermeability characterizing this syndrome.

Ruptured tubo-ovarian abscess complicating transcervical cryopreserved embryo transfer

OBJECTIVE

To present a rare infectious complication related to transcervical ET, without prior transvaginal puncture.

DESIGN

Case report.

SETTING

Hadassah University Hospital, IVF-ET unit.

PATIENT

One patient undergoing cryopreserved-thawed ET.

INTERVENTIONS

Artificial preparation of the endometrium with E2 and P, followed by transcervical intrauterine cryopreserved-thawed embryo transfer.

RESULTS

After ET, severe pelvic inflammatory disease (PID) with ruptured tubo-ovarian abscess was diagnosed and treated.

CONCLUSIONS

Severe PID including tubo-ovarian abscess formation should be considered a potential complication after ET, even without transvaginal oocyte aspiration.

Elevation of serum creatine phosphokinase and its MB isoenzyme during normal labor and early puerperium

BACKGROUND

Chest pain or discomfort are infrequent complaints among women during labor and early puerperium, but when present they raise the suspicion of myocardial ischemia. The diagnosis of the latter is based upon serum elevatIon of certain enzymes, such as aspartate amino transferase, lactate dehydrogenase and creatine phosphokinase. Nevertheless, the normal patterns of these enzymes in the serum during labor and early puerperium have not been characterized well.

OBJECTIVE

To determine serum creatine phosphokinase, lactate dehydrogenase and aspartate amino transferase levels in late pregnancy, and throughout labor and early puerperium.

METHODS

Fifty women having normal pregnancies followed by uneventful vaginal deliveries were prospectively studied for serum lactate dehydrogenase, aspartate amino transferase and creatine phosphokinase including its MB isoenzyme before, during and after labor. Cardiac status was evaluated in all women using serial electrocardiographic and physical examinations.

RESULTS

All women were found to have low to normal antepartum serum enzymes levels. However, during labor total creatine phosphokinase increased markedly, reaching a peak of 2-4 fold baseline levels 24 hours postpartum. It then declined gradually back to baseline. Nulliparous women reached substantially higher levels than multiparous women. The MB or so-called cardio-specific isoenzyme was found to be an important contributor to creatine phosphokinase surge in most women. Correlation was demonstrated between length of the active phase of labor and both total and MB creatine phosphokinase activity. There was no clinical or electrocardiographic evidence for cardiac muscle damage in any of the study patients. Serum lactate dehydrogenase and aspartate amino transferase were not altered during or after labor.

CONCLUSIONS

Serum total creatine phosphokinase and its MB isoenzyme increase substantially during normal vaginal labor without evidence of myocardial ischemia. The uterus and placenta, two organs which were reported to embody substantial amounts of these enzymes, and which participate actively in the process of labor, are thought to release these enzymes to the circulation during labor. Knowing the normal patterns of these enzymes in the serum during labor and puerperium may prevent erroneous diagnoses of myocardial ischemia or infarction. Lack of electrocardiographic abnormalities and low lactate dehydrogenase and aspartate amino transferase levels may assist in excluding such diagnoses.

Surgical treatment of vulvar lichen sclerosus: a review

Surgical therapy of lichen sclerosus of the vulva consists of three main operations: vulvectomy (with or without a skin graft), cryosurgery, and laser ablation. It is indicated in two conditions, either when malignant transformation is present or is likely to occur, or when medical treatment has failed. The overall risk for malignant transformation of vulvar lichen sclerosus is low, ranging between 0 and 9 percent. However, specific histological criteria, such as mixed dystrophy, have recently been associated with higher malignancy rates. Vulvectomy is indicated only when these criteria are met. Both skinning and simple vulvectomies are associated with recurrence rates as high as 50 percent. However, better sexual function and cosmetic results have been reported in the former, especially with concomitant split skin grafting. Cryosurgery also has high recurrence rates, although short-term results are favorable. Although only small series have been reported, laser therapy seems to carry better long-term results than other modes of treatment. Convalescence is complete within 6 weeks posttreatment, and remission rates are as high as 85 percent at 3 years of follow-up. The high recurrence rate of all surgical modalities makes surgical treatment suitable only for patients who failed to respond to multiple medical treatments such as topical high potent steroid ointments, testosterone, and retinoids.

Verapamil increases the bacteriostatic and bactericidal effects of adriamycin on Escherichia coli

The purpose of this study was to evaluate the effect of verapamil on adriamycin-resistant and -sensitive Escherichia coli bacterial strains. Two E. coli strains: B-SR9 and K12-KL16 were incubated with adriamycin in various concentrations in the presence or absence of verapamil. Growth and killing rates were measured using optical densities and colonogenic assays. Transmembrane transport capacity was evaluated by measuring radioactively labelled leucine uptake and intracellular potassium concentrations. While adriamycin (ADR) showed both bacteriostatic and bactericidal effects upon the two bacterial strains, the K12 strain was significantly more resistant to the drug than its peer. Subtoxic concentrations of verapamil augmented these effects in both strains. Verapamil affected bacterial transmembrane transport activity and caused potassium leakage through the cell membrane. Simultaneous exposure to adriamycin and verapamil resulted in rapid, massive damage to membrane functions, indicating accelerated killing rate. The authors concluded that verapamil acts as a potentiator of adriamycin's cytotoxicity in E. coli bacteria in a manner similar to that in multidrug resistant mammalian tumour cells. This observation suggests that the mechanisms of resistance to the drug may be similar in both species.

Intrapartum fetal pulse oximetry: present and future

Pulse oximetry is widely used to monitor the patient's well-being in anesthetic and neonatal practice. As a result of recent technologic and theoretical advances, it has emerged as a clinical tool in intrapartum fetal monitoring. Oximeters record both pulse rate and arterial oxygen saturation of the fetus and they may be adapted to derive an estimate of peripheral perfusion. Reflectance oximetry is more accurate than transmission oximetry in intrapartum fetal management. This method uses the pulsatile changes of red and infrared light reflected from tissue to estimate arterial oxygenation. Pulse oximetry is cheap, non-invasive, simple to operate, relatively accurate and has a fast response time. Factors adversely affecting the accuracy of the pulse oximeter output include transducer displacement, peripheral vasoconstriction, hypotension, anemia, presence of intravascular dyes, meconium staining, fetal hair and scalp edema. Fetal pulse oximetry is limited by a wide normal range and inadequate calibration. The amniochorionic membranes however do not affect oximetry readings so that this method may be applied before rupture of the membranes, i.e. before labor. Once successfully developed, fetal pulse oximetry could potentially be used in combination with other monitoring techniques to reduce instrumental and operative interventions during labor and improve perinatal outcome.

Individual anatomy demands various techniques in correction of an anomalous origin of the left coronary artery in the pulmonary artery

Anomalous origin of the left coronary artery (ALCA) from the pulmonary artery is a rare cardiac anomaly. It can result in decreased myocardial perfusion and impaired left-ventricular function, which can lead to congestive heart failure or even myocardial infarction. Reconstructive surgery of the left coronary artery is the desirable measure in the management of this anomaly. Since July 1992, five patients with ALCA from the pulmonary artery were treated surgically. Age at operation ranged from 3 months to 11 years. Three patients had congestive heart failure and one was in cardiogenic shock. Operative techniques included "tunnel type" surgery in three cases and aortic reimplantation in two. Two operative variations performed successfully in this series are described. There were no postoperative deaths. At the latest follow-up (mean 14 months), all anastomoses were patent and showed antegrade flow. For those patients with ALCA from the pulmonary artery, direct reimplantation of the ALCA to the aorta is the most physiologically appropriate reconstructive solution, and offers good early and late results. Intrapulmonary tunnel from aortopulmonary window to coronary artery is recommended for children in whom aortic reimplantation is not anatomically feasible.

Definitive repair of tetralogy of fallot. A review of 104 cases

Definitive repair of tetralogy of Fallot was performed on 104 children, including 42 younger than 2 years (24 < 1 year and 7 < 6 months). Twenty-two had previous shunt. Transannular patching was required in 60 cases and conduit grafts in two. During 60-day postoperative observation, five patients died. Of the 99 survivors, 93 recovered without complications, three required prolonged mechanical ventilation, two reoperation and one balloon dilatation for residual left pulmonary artery stenosis. Morbidity and mortality were not significantly higher in the patients younger than 12 months, although transannular patching was more common in that age group. Previous shunt operations entailed higher prevalence of distal stenosis and distortion of the pulmonary arteries, which often necessitated surgical repair, and also considerably increased postoperative morbidity and mortality. As the outcome in definitive repair of Fallot's tetralogy is favourable, even in patients younger than 12 months, and as preliminary shunt operations are associated with heightened perioperative morbidity and mortality rates in definitive repair, we advocate the definitive operation for all young patients with severe cyanosis or cyanotic spells.

Repeated repair of tetralogy of Fallot. Report of 11 cases and review of the literature

Eleven patients underwent late repeated correction of tetralogy of Fallot in 1991-1993. The previous operation was repair of simple Fallot's tetralogy in seven cases, repair plus transannular patch in one case and repair of tetralogy and pulmonic atresia in three cases. The indications for reoperation were residual ventricular septal defect, right ventricular outflow tract (R.V.O.T.) obstraction, residual branch pulmonary artery stenosis, aneurysmal dilatation of R.V.O.T. Patch or combination of any of the above. At reoperation these defects were corrected. The post operative course was uneventful in eight patients. Two required mechanical ventilation for 2-3 days, and one underwent another operation for residual branch pulmonary artery stenosis. The functional and haemodynamic results were good in ten patients, and one had residual distal pulmonary artery stenosis. There were no death during 2 years of follow-up. Repeated correction of tetralogy of Fallot thus had low postoperative morbidity and good haemodynamic results. For the relatively few patients initially found to have tetralogy of Fallot and pulmonic atresia, the outcome may be less favorable.

Embryo growth rate in vitro as an indicator of embryo quality in IVF cycles

PURPOSE

The role of embryo growth rate in vitro as an isolated indicator of embryo quality in IVF was evaluated retrospectively.

METHODS

Comparison was made between 98 cycles (group 1), in which only embryos at a cleavage stage of two to three blastomers were transferred, and 99 cycles (group 2), in which all embryos were transferred at a cleavage stage of four or more blastomers. Embryos were transferred at a fixed interval of 42 to 44 h following oocyte insemination. The mean patients' age, number of oocytes recovered and number of embryos transferred per cycle were similar in both groups.

RESULTS

The pregnancy rate and the take-home-baby rate were significantly higher in group 2 as compared to group 1 (22.2% vs 7.1% and 16.2% vs 4.1%; P < 0.05 and P < 0.001, respectively).

CONCLUSIONS

These results demonstrate that embryos with a slow cleavage rate in vitro are less likely to produce pregnancy following IVF-ET and that the cleavage stage is a valuable criteria in the selection of the best embryo for transfer.