Laparoscopic removal of a dermoid cyst in pregnancy. A case report.

BACKGROUND: Laparoscopy in pregnancy can endanger the fetus. It is now being reexamined because of our experience with complex operative procedures and new laparoscopic equipment. CASE: A decision was made to perform laparoscopy instead of laparotomy for a pelvic mass in a pregnant woman. The patient was admitted to the emergency room with a temperature of 38.9 degrees C and was 15 4/7 weeks pregnant. Over several hours she developed septic shock, with the blood pressure and white blood cell count dropping. Bedside ultrasound revealed a complex mass suspicious for an abscess. A dermoid cyst was found and removed by pelviscopic techniques. Blood cultures revealed typhoid fever, and the patient responded to antibiotics. She was discharged on the 10th postoperative day. CONCLUSION: This case demonstrates the value of laparoscopy in pregnancy not only for diagnosis but also for treatment. Laparoscopy in pregnancy should be added to the armamentarium of the gynecologist.

[Analysis and epidemiology of gallstones in deceased and autopsied patients of the Thurgau canton]. / Analyse und Epidemiologie von Gallensteinen anhand im Kanton Thurgau verstorbener und obduzierter Patienten.

In our postmortem examinations of patients in the canton of Thurgau from May 1989 through December 1991 we found a cholelithiasis or a condition after a cholecystectomy of gallstones in 44% of the women and 23% of the men. While gallstones were found in only 11% of the women and 7% of the men up to age 50, half of all women and every third man in the age group over 90 had gallstones. Among the gallstone carriers, 8% of the women and 2.5% of the men had developed a gall bladder--gall duct carcinoma. Where a liver cirrhosis was present, gallstones occurred at nearly the same rate in both sexes (45%/44%). 33% of the persons with gallstones had a solitary stone, and 31% had more than 10 stones. More than a third of all stones had a cholesterol content of more than 80%, and every seventh stone had a bilirubin content higher than 80%. The calcium content of more than 40% of the stones exceeded 5%. The examination for bilirubin can be easily performed with some exercise by means of the bilirubin test field on the urine sticks supplied by the Boehringer Mannheim company.

[Respective role of the size, location and composition of the calculus as determinants of therapeutic success after extracorporeal shock wave lithotripsy in renal lithiasis]. / Rôle respectif de la taille, de la localisation et de la composition du calcul en tant que déterminant du succès thérapeutique après lithotritie par ondes de choc extracorporelles dans la lithiase rénale.

We evaluated the respective role of size, location and composition of renal stones as determinants of the outcome of extracorporeal shock wave lithotripsy (ESWL). The analysis of the chemical composition and of the morphology of the fragments eliminated by hundred patients who underwent ESWL has been made by X-rays diffraction. Results showed that the larger the stone, the higher the risk of having to perform an extra intervention (additional sessions of ESWL, percutaneous nephrostolithotomy, nephrolitholapaxy) or of finding residual fragments at the three month check-point. In addition, the location of the stone in a calice, especially a lower calice, strongly predisposes to incomplete elimination of the fragments. Finally, two types of stones appear to lessen the probability of success of ESWL: those of struvite and those of cystine. Indeed, out of eleven ESWL performed on struvite stones (pure or mixed), two had to be completed by percutaneous nephrolitholapaxy and even one by a nephrectomy because of superinfection. Out of the four patients with cystine stones, two had to be treated by additional percutaneous nephrolitholapaxy because of inadequate fragmentation after ESWL. However, for the remaining types of stones (pure or mixed) chemical composition seems to be less important than size or location.

Treatment of cutaneous infections. Worldwide experience with ciprofloxacin.

Oral ciprofloxacin, a new fluorinated 4-quinolone, was evaluated in 795 patients with skin and skin structure infections. Ninety-four point one percent of the patients treated had clinical success with eradication of almost all of the offending bacteria. Ciprofloxacin has good activity against gram-positive organisms and excellent activity against gram-negative organisms. Side effects were few and not considered significant.

Systemic treatment of cutaneous infections. A comparative study of ciprofloxacin and cefotaxime.

A prospective, double-blind, randomized study of hospitalized patients with skin and skin structure infections was conducted to compare orally administered ciprofloxacin and conventional intravenous cefotaxime therapy. Fifty-six patients, predominantly elderly women, were randomly assigned to receive either ciprofloxacin (24 patients, 25 infected sites) or cefotaxime (32 patients, 36 sites). Patients in the ciprofloxacin group received 750 mg of orally administered ciprofloxacin every 12 hours plus a placebo infusion while the other group received 2.0 g of cefotaxime intravenously every eight hours plus a placebo tablet every 12 hours. The average duration of treatment was seven to 10 days, with a maximum of 21 days. Clinical response per infected site in the ciprofloxacin group was as follows: resolution in 88 percent, improvement in 8 percent, and failure in 4 percent. In the cefotaxime group, there was resolution in 69 percent, improvement in 25 percent and failure in 6 percent. Bacteriologic response per site in the ciprofloxacin group was eradication in 88 percent and persistence in 12 percent. With cefotaxime there was 69 percent eradication, 3 percent marked reduction, 6 percent recurrence, and 22 percent persistence. Clinical and bacteriologic responses were combined using an algorithm to derive a cure rate, which was 91 percent for ciprofloxacin and 61 percent for cefotaxime (p = 0.0214).

[Long-term problems of levodopa therapy in Parkinson disease]. / Langzeitprobleme der Laevodopa-Therapie bei der Parkinsonschen Krankheit.

The dependence of motor side effects of L-DOPA therapy on clinical and pharmacodynamic parameters was investigated in 28 patients with Parkinson's disease. Duration of disease and degree of motor impairment were significantly less in a first group of 12 patients without motor side effects than in a second group of 16 patients with fluctuations of antiparkinsonian effects and dyskinesias. The two groups showed different pharmacodynamic patterns: the antiparkinsonian effect in the first group remained unchanged, with decreasing DOPA plasma concentrations (Type I), whereas in the second group a direct correlation between DOPA plasma levels and antiparkinsonian effect was observed (Type II). A possible mechanism for the different pharmacodynamic patterns and its relevance for therapy are discussed.

[Esophageal obstruction in tube feeding: a result of protein precipitation caused by antacids?]. / Osophagusobstruktion während Sondenernährung: Folge von Eiweissfällung durch Antazida?

A complication of tube feeding, i.e. thickening of nutrient solution in the presence of an antacid leading to obstruction of the esophagus, is reported. Three patients on artificial breathing where fed by tube with Fresubin liquid. At intervals, Alucol liquid was given for stress ulcer prevention through the tube. After 2, 4, and 50 days respectively, reflux of nutrient solution into the mouth occurred. On removal of the tube a compact, yellowish-white substance was extracted. Endoscopically, residual particles were found in the upper part of the esophagus and in the hypopharynx which obstructed the esophagus completely and in one case could only be extracted through a rigid esophagoscope. In vitro studies showed that thickening of the nutrient solution was due to interaction with antacids administered simultaneously with the nutrient.

Aspiration pneumonia: a review.

The damage caused by aspiration depends on the volume, nature and pH of the aspirate and the type of pathogen involved. Aspirate with a pH below 2.5 is much more likely to be toxic than less acidic material. Anaerobic organisms are common pathogens, but aerobic bacteria frequently appear in the hospital setting. Steroids may be useful if administered within minutes of the aspiration. Lavage with large amounts of alkaline fluid has not proved helpful.

Critical aspects of urine and stone analysis. Appearance of iatrogenic urinary calculi.

In 25% of the samples the often applied qualitative chemical analysis of urinary stones leads to entirely wrong results with severe therapeutic consequences. The appropriate techniques for stone analysis are infrared spectroscopy and X-ray powder diffraction. These techniques make also possible the identification of iatrogenic urinary calculi. Four types of such stones were detected here, caused by modern medication. N4-acetylsulfamethoxazole, N4-acetylsulfadiazine, mefenamic acid and silicon dioxide. It is only the correct preanalytical treatment of urine samples that prevents considerable impairment of analytical results. Without precautions especially, the oxalate concentration in urine may be doubled or tripled during one day of storage.

Clinical significance of stone analysis.

The bases of a real metaphylaxis in the renal stone diseases are the analysis of stones and the research of metabolism in blood plasma and urine. The greatest part of the stones analyzed may be classified in four groups: oxalate, phosphate, uric acid and cystine. The metaphylaxis by whewellite and weddellite is the same for both species but there is a distinction in growth and recurrence. In the phosphate stones, the section with the most different composition, a postoperative therapy is only possible with the distinction of 'acid' and 'alkaline' stones. The uric acid and cystine stones need a tight supervision and metaphylaxis for the whole life. On the basis of 15,000 analyses with X-ray diffraction the difference of the renal stones is discussed and the deducation for a genuine metaphylaxis is shown.

Epidemiology and socioeconomic aspects of urolithiasis.

This epidemiologic study reveals that the occurrence of urolithiasis in the nineteenth century population in Europe is quite similar to that of the twentieth century in Asia. The analogy is demonstrated for age distribution, stone localization, male/female ratio, and stone composition. The distribution of urolithiasis in a low socioeconomic level population is defined by: highest frequency in childhood, more than 40% bladder stones, less than 20% female patients, less than 40% calcium-oxalate stones, and more than 30% uric acid/urate stones. Typical for a population with a high level these characteristics of urolithiasis are: highest frequency among adults, less than 10% bladder stones, more than 25% female patients, more than 60% calcium oxalate stones, and less than 20% uric acid/urate stones. In partially developed countries those values fall in between.

[Size and formation of crystals in urinary calculi studied with x-ray diffraction profiles]. / Etude de la taille et de la formation des cristaux dans des calculs urinaires par l'analyse des profils de raies de diffraction des rayons X.

Application on in vivo grown urinary calculi shows that crystals of uric.acid.dihydrate and calcium.oxalate.dihydrate are larger than crystals of uric.acid.siccum and calcium.oxalate.monohydrate. These findings could be explained by the hypothesis, that dehydrated forms are secondary formations out of dihydrate crystals.

[Stress and urolithiasis]. / Stress und Urolithiasis.

Stress is a response state of the body which may be evoked by various stimuli. The effect of such stress factors on the quantitative composition of 24-hour urine in young male Wistar rats is examined using short, repetitive, weak electric impulses. Changes in body development and, in particular, of the absolute and relative increases in size and weight of the adrenal glands compared with control groups are used as evidence of the endured stress procedure. Three 24-hour urine groups can be clearly distinguished. While concentrations of calcium and sodium remain unaltered by the adaptation syndrome of the body, the concentrations of potassium and magnesium are clearly reduced during the first days of the stress period compared with the control group. Inorganic phosphorus and uric acid concentrations, however, are markedly increased during the experimental period. The combination of increased uric acid and inorganic phosphorus concentrations and reduced potassium and magnesium levels favors a disposition to urolithiasis since uric acid and inorganic phosphorus are recognized promoters, and potassium and magnesium are known inhibitors, of stone formation.

Potentiometry of Na+ in undiluted serum and urine with use of an improved neutral carrier-based solvent polymeric membrane electrode.

We present an improved Na+-selective liquid membrane electrode for measurement of Na+ concentrations in both undiluted serum and urine. The values for urinary Na+ obtained with the ion-selective electrode agree well with those obtained with the flame photometer. The correlation gives a standard residual deviation of +/- 2.7 mmol/L over the Na+ range of 25-280 mmol/L. In serum, this direct potentiometry yields Na+ concentrations 5.4% (SD 1.1%) higher than those obtained by atomic spectrometry and a standard residual deviation of +/- 1.1 mmol/L. Correction of these values for the volumes of protein and lipid leads to potentiometric values 1.2% (SD 0.7%) lower than those by flame photometry (residual standard deviation: +/- 1.0 mmol/L). Other factors that possibly contribute to this discrepancy are discussed.