Levoatrial cardinal vein in mitral atresia and closed foramen ovale: prenatal diagnosis and perinatal management

A levoatrial cardinal vein is a rare cardiovascular anomaly that may be present in malformed hearts with severe left heart obstruction and restrictive interatrial communication. We report the prenatal diagnosis at 23 weeks of a fetus with mitral atresia, double-outlet right ventricle, premature closure of the foramen ovale and a levoatrial cardinal vein draining into the innominate vein. In a prior examination performed elsewhere the levoatrial cardinal vein had been interpreted as an aortic arch perfused retrogradely, and hypoplastic left heart syndrome with aortic atresia had been diagnosed. Prenatal management, induction at 38 weeks and postnatal examinations and treatment are reported. To the best of our knowledge, this is the first reported prenatal diagnosis of this embryological vessel, presenting a potential pitfall for prenatal echocardiography.

Patients' sensation during and after laserneedle versus metal needle treatment

OBJECTIVES: Aim of the study was to evaluate the patients' sensations during and after laserneedle versus metal needle acupuncture. STUDY DESIGN: The prospective study was performed at the gynaecological outpatient department of a University Teaching Hospital of Bern, Switzerland. Thirty female patients per group were included in the study and randomized into laserneedle or metal needle group. All women visited the acupuncture out patient department because of gynaecological disorders. Age of the patients in the metal needle group was 38 years in median (range 18-73 years); mean age was 41+/-13.3. Age in the laserneedle group was 36 years in median (range 16-60 years) and mean age was 39.1+/-12.2. Interventions were laserneedle acupuncture and metal needle acupuncture. Patients answered a questionnaire before, after the first treatment and prior to the second treatment. The questionnaires asked about the patients' knowledge of the various acupuncture methods and their health condition before treatment, their perception of pain, warmth, tiredness and relaxation during or after application of the needles or during or after the treatment. Statistics were performed by Graph Pad InStat 3 for windows. RESULTS: The common metal needle technique was well known by the patients in comparison to the laserneedle method (p<0.0001***). Laserneedle acupuncture is a method which is painless (p<0.0001***), energy inducing and relaxing (p=0.0257*) which leads to a warming sensation (p=0.0009***) during treatment. CONCLUSION: Both methods laserneedle and metal needle acupuncture are valuable methods in achieving relaxation and improvement of gynaecological symptoms. Laserneedle acupuncture is painless and easy to apply which is a valuable reason to support this technique in the future.

A diagnostically challenging case of ureterovaginal fistula after laparoscopic hysterectomy

A complicated case of iatrogenic ureterovaginal fistula in a 56-year-old woman after laparoscopic-assisted vaginal hysterectomy, which persisted after several attempts of repair including ureterocystoneostomy, is presented. Accurate radiologic work-up enabled us to identify a refluxing ureteral stump, which was not ligated at the time of ureterocystoneostomy, as the origin of urinary leakage. Surgical principles that should be adhered to when managing such complex cases to obtain successful long-lasting outcome are described.

Interrelation of peri-operative morbidity and ASA class assignment in patients undergoing gynaecological surgery

OBJECTIVE: The aim of this study was to estimate intra- and post-operative risk using the American Society of Anaesthesiologists (ASA) classification which is an important predictor of an intervention and of the entire operating programme. STUDY DESIGN: In this retrospective study, 4435 consecutive patients undergoing elective and emergency surgery at the Gynaecological Clinic of the University Hospital of Zurich were included. The ASA classification for pre-operative risk assessment was determined by an anaesthesiologist after a thorough physical examination. We observed several pre-, intra- and post-operative parameters, such as age, body-mass-index, duration of anaesthesia, duration of surgery, blood loss, duration of post-operative stay, complicated post-operative course, morbidity and mortality. The investigation of different risk factors was achieved by a multiple linear regression model for log-transformed duration of hospitalisation. RESULTS: Age and obesity were responsible for a higher ASA classification. ASA grade correlates with the duration of anaesthesia and the duration of the surgery itself. There was a significant difference in blood loss between ASA grades I (113+/-195 ml) and III (222+/-470 ml) and between classes II (176+/-432 ml) and III. The duration of post-operative hospitalisation could also be correlated with ASA class. ASA class I=1.7+/-3.0 days, ASA class II=3.6+/-4.3 days, ASA class III=6.8+/-8.2 days, and ASA class IV=6.2+/-3.9 days. The mean post-operative in-hospital stay was 2.5+/-4.0 days without complications, and 8.7+/-6.7 days with post-operative complications. Multiple linear regression model showed that not only the ASA classification contained an important information for the duration of hospitalisation. Parameters such as age, class of diagnosis, post-operative complications, etc. also have an influence on the duration of hospitalisation. CONCLUSION: This study shows that the ASA classification can be used as a good and early available predictor for the planning of an intervention in gynaecological surgery. The ASA classification helps the surgeon to assess the peri-operative risk profile of which important information can be derived for the planning of the operation programme.

Comparative study of the neuropeptide-Y sympathetic nerves in endometriotic involved and noninvolved sacrouterine ligaments in women with pelvic endometriosis

STUDY OBJECTIVE: To show the relationship between the neuropeptide-Y pelvic sympathetic nerves and neoangiogenesis in the development of endometriosis DESIGN: Prospective study. SETTING: Academic community teaching hospital. PATIENTS: Fifteen consecutive women with unilateral endometriotic infiltration of the sacrouterine ligaments. INTERVENTIONS: A laparoscopic excision/biopsy of involved and noninvolved parts of the sacrouterine ligaments were taken. The sections were incubated with the neuronal marker rabbit polyclonal anti-protein gene product 9.5 and rabbit polyclonal anti-neuropeptide-Y. We made a comparative study on the distribution of nerve fibers and their relationship to the vessels on intact and endometriotic involved tissue. MEASUREMENTS AND MAIN RESULTS: The results show that a large amount of nerves are present around the blood vessels in the endometriosis samples, and a large number of these nerves are neuropeptide-Y sympathetic nerves. Adrenergic fibers are also present in the intact control subjects, however, in significantly smaller amounts. CONCLUSION: This finding shows a strong relationship between the neuropeptide-Y sympathetic pelvic nerves and the neoangiogenesis required for the development of endometriosis.

Virtual reality ultrasound imaging of the normal and abnormal fetal central nervous system

OBJECTIVES: In fetal ultrasound imaging, teaching and experience are of paramount importance to improve prenatal detection rates of fetal abnormalities. Yet both aspects depend on exposure to normal and, in particular, abnormal 'specimens'. We aimed to generate a number of simple virtual reality (VR) objects of the fetal central nervous system for use as educational tools. METHODS: We applied a recently proposed algorithm for the generation of fetal VR object movies to the normal and abnormal fetal brain and spine. Interactive VR object movies were generated from ultrasound volume data from normal fetuses and fetuses with typical brain or spine anomalies. Pathognomonic still images from all object movies were selected and annotated to enable recognition of these features in the object movies. RESULTS: Forty-six virtual reality object movies from 22 fetuses (two with normal and 20 with abnormal brains) were generated in an interactive display format (QuickTime) and key images were annotated. The resulting .mov files are available for download from the website of this journal. CONCLUSIONS: VR object movies can be generated from educational ultrasound volume datasets, and may prove useful for teaching and learning normal and abnormal fetal anatomy.

Prenatal sonographic diagnosis of skeletal dysplasias

OBJECTIVE: To assess the types and numbers of cases, gestational age at specific prenatal diagnosis and diagnostic accuracy of the diagnosis of skeletal dysplasias in a prenatal population from a single tertiary center. METHODS: This was a retrospective database review of type, prenatal and definitive postnatal diagnoses and gestational age at specific prenatal diagnosis of all cases of skeletal dysplasias from a mixed referral and screening population between 1985 and 2007. Prenatal diagnoses were grouped into 'correct ultrasound diagnosis' (complete concordance with postnatal pediatric or pathological findings) or 'partially correct ultrasound diagnosis' (skeletal dysplasias found postnatally to be a different one from that diagnosed prenatally). RESULTS: We included 178 fetuses in this study, of which 176 had a prenatal ultrasound diagnosis of 'skeletal dysplasia'. In 160 cases the prenatal diagnosis of a skeletal dysplasia was confirmed; two cases with skeletal dysplasias identified postnatally had not been diagnosed prenatally, giving 162 fetuses with skeletal dysplasias in total. There were 23 different classifiable types of skeletal dysplasia. The specific diagnoses based on prenatal ultrasound examination alone were correct in 110/162 (67.9%) cases and partially correct in 50/162 (30.9%) cases, (160/162 overall, 98.8%). In 16 cases, skeletal dysplasia was diagnosed prenatally, but was not confirmed postnatally (n = 12 false positives) or the case was lost to follow-up (n = 4). The following skeletal dysplasias were recorded: thanatophoric dysplasia (35 diagnosed correctly prenatally of 40 overall), osteogenesis imperfecta (lethal and non-lethal, 31/35), short-rib dysplasias (5/10), chondroectodermal dysplasia Ellis-van Creveld (4/9), achondroplasia (7/9), achondrogenesis (7/8), campomelic dysplasia (6/8), asphyxiating thoracic dysplasia Jeune (3/7), hypochondrogenesis (1/6), diastrophic dysplasia (2/5), chondrodysplasia punctata (2/2), hypophosphatasia (0/2) as well as a further 7/21 cases with rare or unclassifiable skeletal dysplasias. CONCLUSION: Prenatal diagnosis of skeletal dysplasias can present a considerable diagnostic challenge. However, a meticulous sonographic examination yields high overall detection. In the two most common disorders, thanatophoric dysplasia and osteogenesis imperfecta (25% and 22% of all cases, respectively), typical sonomorphology accounts for the high rates of completely correct prenatal diagnosis (88% and 89%, respectively) at the first diagnostic examination.

Vaginal voiding: a common cause of daytime urinary leakage in girls

STUDY OBJECTIVE: To estimate the frequency of vaginal voiding as the cause of daytime urinary leakage in girls, and to study the effect of instructions intended to alleviate the problem. SETTING: Girls with vaginal voiding were identified in a group of girls referred because of daytime urinary leakage. They were evaluated by a noninvasive screening protocol. Girls with vaginal voiding were instructed on how to achieve better toilet habits. PARTICIPANTS: Twelve girls with vaginal voiding. RESULTS: Vaginal voiding was found in 12 of 39 girls with daytime urinary leakage. Their age ranged between 8.5 and 13.9 years. They all had history of small leakage immediately after voiding. A body mass index greater than the corresponding 85th percentile was noted in 5 girls, and labial fusion was noted in 2 girls. The complaint disappeared in 10 girls and improved in the remaining 2 girls after instructions on how to achieve better toilet habits. CONCLUSIONS: Vaginal voiding is common in girls. It occurs in girls at risk of overweight, in girls with labial fusion, and in girls adopting a hairpin posture while sitting on the toilet. The diagnosis is obtained by an adequate history. Proper voiding instructions resolve the problem.

Clean intermittent self-catheterization after botulinum neurotoxin type A injections: short-term effect on quality of life

OBJECTIVE: To investigate the hypothesis that the need for clean intermittent self-catheterization after botulinum neurotoxin type A injections is outweighed by the efficacy of this treatment, so that clean intermittent self-catheterization is not a burden for patients with refractory idiopathic detrusor overactivity. METHODS: Women undergoing intradetrusor injections of 200 units botulinum neurotoxin type A for refractory idiopathic detrusor overactivity were evaluated prospectively. Clean intermittent self-catheterization was discussed with all patients and its possible need after botulinum neurotoxin type A treatment. As indicator of quality of life, lower urinary tract symptom distress and effect on daily activities were assessed using the validated Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7) before and 4 weeks after receiving botulinum neurotoxin type A injections. RESULTS: Mean age of the 65 women was 51 years, and all voided spontaneously before botulinum neurotoxin type A injections. After botulinum neurotoxin type A treatment, 28 (43%) required clean intermittent self-catheterization. Mean UDI-6 and IIQ-7 scores reduced from 61 to 33 (P<.001) and 62 to 30 (P<.001) in women performing clean intermittent self-catheterization and from 60 to 28 (P<.001) and 64 to 25 (P<.001) in those who did not, respectively. Comparison of quality of life in women performing clean intermittent self-catheterization and in those who did not revealed no significant differences before and after botulinum neurotoxin type A treatment. CONCLUSION: Clean intermittent self-catheterization after botulinum neurotoxin type A intradetrusor injections did not impair quality of life in appropriately informed and selected women in the short term. All patients should be informed of the potential need for clean intermittent self-catheterization after botulinum neurotoxin type A injections, and a willingness to do so should be a prerequisite for this still unlicensed off-label treatment.