Ferriman-Gallwey scores, serum androgen and mullerian inhibiting substance levels in hirstute adolescent girls.

OBJECTIVE: To study Ferriman-Gallwey (FG) scoring in adolescents with an aim to correlate these scores with serum androgens and mullerian inhibiting substance (MIS). DESIGN: Cross sectional study. SETTING: Pediatric and Adolescent Gynecology Clinic of a university hospital. PATIENTS: Twenty-four hirsute adolescent girls age 12-19 with a FG score of 6 or greater. INTERVENTIONS: FG examination and collection of serum levels of MIS, total testosterone, free testosterone, follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, cortisol, and androstenedione. MAIN OUTCOME MEASURES: Correlation between FG scores in adolescents and serum androgens and MIS. RESULTS: Weak correlations were seen between FG score and FSH, free-testosterone, total testosterone, and cortisol. Increasing FG scores correlated with an increase in cortisol. As FG score increased, FSH, free-testosterone, and total testosterone decreased. There was no statistical relationship between FG score and LH, androstenedione, prolactin, and MIS. There were weak positive correlations between MIS levels and FSH, total testosterone, and androstenedione. There was no evidence for a linear relationship between MIS levels and LH, free testosterone, cortisol, prolactin, and FG score. CONCLUSIONS: The utility of FG scoring in adolescents is unknown. There were no direct correlations found with MIS levels and FG score. MIS was not found to be a predictor of hirsutism. A larger study is needed to assess the clinical relevance of FG scoring and presence of underlying causes of hirsutism in adolescents.

Successful combination therapy of a proximal haemophilic pseudotumour with surgery, radiation and embolization in a child with mild haemophilia A.

We describe the management of a young boy with mild haemophilia A and a massive iliac pseudotumour with a multi modality approach involving factor replacement, radiation therapy, embolization and surgery. The patient was initially treated with recombinant factor VIII and radiation therapy. Because of inadequate response and worsening of bony erosion, the patient had a preoperative embolization followed by surgical excision. The surgical procedure was associated with minimal blood loss and the patient had a relatively smooth postoperative course with no physical morbidity. This case illustrates successful aggressive management of a large, proximally located pelvic pseudotumour, which resulted in an excellent outcome despite the need for a normally morbid operation.

Surgical and anesthetic decisions for children with terminal illness.

Terminal conditions such as congenital anomalies and cancer are a significant source of infant and childhood mortality. Many terminally ill children are considered for operative procedures each year. These procedures may be palliative or elective, and the prognosis and natural course of the terminal illness play a significant role in determining the appropriateness of the surgical procedure. Providing anesthesia to a terminally ill patient is a complex task requiring an appropriate balance between adequate anesthesia and hemodynamic normality. Some children with a terminal condition will have a standing "Do-Not-Resuscitate" order that should not necessarily be reversed. Surgeons, anesthesiologists, and family members must consider a number of factors when determining the appropriateness of an operation for a dying patient, including the rights of the child.

Beneficial effects of a hospital bereavement intervention program after traumatic childhood death.

PURPOSE: An investigation of the experiences of parents grieving the traumatic death of their child, the initiatives that helped, and common parental concerns that would benefit from improved education. METHODS: From January 1, 1995, to December 31, 1998, 81 of 3,501 children admitted to our pediatric trauma center died. An attempt was made to enroll all parents. Interactions included family contact at hospital, home/funeral home visit within 1 month of death, educational meeting with parents and 15 supporters at a restaurant within 2 months of death, follow-up survey to parents/supporters, and final interview/survey with parents in 1999-2000. RESULTS: Seventy-seven families were enrolled; 59 families completed the educational meeting with supporters, and 245 parental supporters returned surveys. Supporters were likely to use proposed interventions (82%), were more accepting of the duration of grief (94%), and interacted with parents more often after the death (78%). Parents (n = 44) felt the hospital staff was appropriately sensitive to their child (90%), themselves (93%) and prepared them for their child's death (81%). Parents (n = 54) on behalf of 37 children have completed the final interview. Poor conceptualization of aspects of the medical care and brain death, and delayed regret for missing the opportunity to donate organs, were recurring themes. CONCLUSION: We conclude that parents' unanswered questions or misconceptions regarding brain death, organ donation, and their child's medical care adversely affect their grief; that "normal life" for parents is challenged as they struggle to establish a new sense of normal; and that hospital and trauma service personnel can positively impact the grieving process with appropriate training.

The management of mature cystic teratomas in children and adolescents: a retrospective analysis.

Mature cystic teratomas (MCT) are the most common ovarian tumours seen in children and adolescents. Fifty-two patients <21 years of age had surgical removal of an MCT, 14 of whom were approached laparoscopically. Compared with laparotomy, those patients managed laparoscopically had a significantly shorter hospital stay. Intra-operative tumour spillage occurred in 27 (52%) patients; there were no cases of chemical peritonitis. Available follow-up data on 34 (65%) patients revealed seven pregnancies occurring at a median of 70 months (46-123) postoperatively, including four in patients with intraoperative MCT spill. There were no cases of tumour recurrence during the follow-up period among the 27 (52%) patients managed with ovarian cystectomy. These results demonstrate that some of the conclusions regarding the contemporary management of MCT in adults are applicable to children and adolescents.

Managing mature cystic teratomas of the ovary.

Mature cystic teratomas (MCT), commonly called dermoid cysts, are the most common benign germ cell tumors of the ovary in women of reproductive age. Future fertility is of major concern among these women; therefore, the surgical management must focus on preserving ovarian tissue and minimizing adhesion formation. Patients requiring surgery should be appropriately counseled about the risks and benefits of laparoscopy and laparotomy, the risks of intraoperative MCT spillage and adhesion formation. In addition, the risks of recurrence and malignant transformation should be discussed. The parents of children with MCTs have the same concerns as older women and a similar discussion should take place. The goal of this article is to review these issues and provide the physician with the information to counsel their patients preoperatively.

The clinical course of unresected ovarian torsion.

The authors report the clinical course of a young girl with ovarian torsion who was treated conservatively. This case shows that detorsion of the ovary may be associated with immediate postoperative febrile morbidity and slow resolution of ovarian enlargement. The authors emphasize that these signs can be associated with viable ovarian tissue and are not necessarily an indication for oophorectomy.

Noninflammatory ovarian masses in girls and young women.

OBJECTIVE: We reviewed the presentation, treatment, and pathologic diagnoses of girls and young women less than 21 years old with noninflammatory ovarian masses that required surgery and established whether treatment had changed over time. METHODS: We retrospectively reviewed charts of all girls and young women under 21 years old with International Classification of Diseases, 9th Revision (ICD-9) codes specific for noninflammatory ovarian masses treated at our institution from June 1980 to July 1998 (n = 140). RESULTS: The median age at surgery was 15 years (range 2 days-21 years). Ovarian cysts occurred in 57.9% (81 of 140) of patients, benign tumors (including mature cystic teratomas) in 30% (42 of 140), malignant tumors in 7.9% (11 of 104), and torsed but normal ovaries in 4.3% (six of 140) of the study sample. Patients older than 15 years were more likely to have ovarian cysts and benign tumors than younger patients (P =.019). There were no malignancies among girls with neonatal cysts. The incidence of ovarian torsion was 17.8% (25 of 140). Patients with ovarian cysts, mature cystic teratomas, and normal ovaries were more likely to have torsion than those with other benign or malignant tumors (P <.001). Operative approach and surgical procedure were compared before and after July 1, 1989. Laparoscopy was performed more commonly after July 1, 1989 (P =.009). However, patient age (P <.001) rather than time of surgery (P =.83) was the most important predictive factor in a multivariate analysis for use of laparoscopy. In addition, multivariate analysis revealed that patient age (P =.02) rather than time of surgery (P =.79) was also predictive of surgeon type (gynecologist or pediatric surgeon). CONCLUSION: The most frequent cause of an ovarian mass requiring surgery in a girl or young woman under 21 years of age is an ovarian cyst, which justifies consideration of a laparoscopic approach. Patient age rather than time of surgery predicted operative approach and surgeon type. Caution should be exercised in patients over age 12 months with a complex mass on ultrasound and clinical evidence of hormonal activity, as these masses are usually malignant.

Serum müllerian-inhibiting substance levels during normal menstrual cycles.

OBJECTIVE: To measure serum levels of müllerian-inhibiting substance (MIS) during the normal menstrual cycle. DESIGN: Serum was collected from women during ovulation and the mid-luteal and early follicular phases of the menstrual cycles. It was stored frozen at -80 degrees C until assayed. SETTING: University of Louisville Departments of Obstetrics and Gynecology and Surgery. PATIENT(S): Twenty healthy women 22-35 years of age with normal menstrual cycles. INTERVENTION(S): Blood samples were collected on menstrual cycle day two or three and on the day of LH surge plus one and plus seven or eight. MAIN OUTCOME MEASURE(S): Serum MIS levels were measured by using an enzyme-linked immunosorbent assay. RESULT(S): Serum MIS levels ranged from a low of 1.4 +/- 0.9 ng/mL (mean [+/-SD]) in the early follicular phase, peaked mid-cycle at 1.7 +/- 1.1 ng/mL, and decreased to 1.4 +/- 0.9 ng/mL in the mid-luteal phase of the normal menstrual cycle. CONCLUSION(S): Fluctuations in serum MIS levels during the menstrual cycle suggest that MIS may have a regulatory role in folliculogenesis.

Effects of vasoactive intestinal peptide on human sperm motility.

Sperm flagellar activity is modulated by cAMP. In target tissues, vasoactive intestinal peptide (VIP) stimulates adenyl cyclase activity, which elevates intracellular cAMP levels and activates protein kinase activity. This study investigated the effects of VIP on motility of sperm from 17 subjects. Motile activities, monitored before (0 min, baseline) and for 40 min after incubation with VIP (0.2 microgram/mL cell suspension), were analyzed by computer-assisted semen analysis. The data (mean +/- SEM) are expressed as percentages of baseline values and changes were compared by trend analysis for interval level measures by repeated measures analysis of variance orthogonal polynominal contrasts. The addition of VIP significantly increased motile sperm concentration (110 +/- 17% [10 min], 132 +/- 15% [20 min], 152 +/- 18% [30 min], 125 +/- 18% [40 min]; p < .02) and sperm with rapid straight-line motility (V > 25 microns/s) (167 +/- 20%, 174 +/- 19%, 173 +/- 23%, 141 +/- 16%; p < .02). Mean track speed (micron/s) was increased (125 +/- 12%, 134 = 9%, 129 +/- 12% and 126 +/- 12%; p < .02), while mean progressive velocity, amplitude of head displacement, and beat frequency were not affected by VIP. These results indicate that VIP stimulates sperm motile activity by cAMP-mediated phosphorylation of axonemal proteins.

Müllerian inhibiting substance improves longevity of motility and viability of fresh and cryopreserved sperm.

Müllerian inhibiting substance (MIS) is a hormone present in seminal plasma, but its role is unknown. In this study, the effects of MIS on sperm survival in fresh and cryopreserved specimens were investigated. Fresh sperm motility and viability (n = 12) were evaluated in specimens after 0, 0.5, 1, 3, 5, and 22 hours of incubation in the presence or absence of MIS. Motile and nonmotile sperm were evaluated in Cell-Vu counting microscope slides, and viability was assessed by eosin-nigrosin exclusion. Sperm cryopreserved for 2 weeks in TES (N-Tris[hydroxymethyl]methyl-2-aminoethanesulfonic acid)-Tris-glycerol-egg yolk buffer and 4% glycerol with or without MIS were thawed at room temperature (n = 6) and were evaluated for motility and viability using identical methods to those used with fresh sperm. The effects of MIS were examined by coincubation with monoclonal anti-MIS antibody (6E11; n = 6). In fresh and cryopreserved sperm incubated with MIS, both motility and viability were higher than in the absence of MIS (P < 0.03; Wilcoxon signed rank test) at 5 and 22 hours. Coincubation with anti-MIS antibody eliminated the effects of MIS. Longevity of sperm motility and viability are improved both in fresh and cryopreserved sperm in the presence of MIS and may have potential for use in assisted reproductive technology.

Central venous catheter bloodstream infections in the neonatal intensive care unit.

PURPOSE: The goal of this study was to identify symptoms and signs related to central venous catheter (CVC) bloodstream infections (BSI) in neonatal intensive care unit (NICU) patients that would predict infection and to identify factors that might influence CVC longevity. METHODS: This was a retrospective cohort study evaluating 268 lines representing a total of 5,212 CVC days placed in 157 NICU patients over 29 months by the pediatric surgery and neonatology services at one children's hospital. Centers for Disease Control (CDC) criteria were used to determine laboratory-confirmed BSI. Data were analyzed by univariate methods and logistic regression and determined significant at the P less than .05 level. RESULTS: Sixty-five lines (24%) from 54 patients had confirmed CVC BSI. Fever (49%) and pulmonary dysfunction (30%) were the most common symptoms of CVC BSI. Erythema or purulent discharge at the insertion site was found in only 20% of cases. Staphylococcus epidermidis was the most common organism isolated. Factors that significantly decreased the incidence of CVC BSI were increasing estimated gestational age (EGA; P < .0013) attime of insertion, associated vancomycin use at the time of catheter placement (P < .0057), and fewer days of catheter use (P < .0291). There were no significant differences noted caused by line location or catheter type. CONCLUSION: Fever and pulmonary dysfunction were the most common signs of CVC BSI in neonates. Lower EGA and increased catheter duration were significantly correlated with infection. The use of vancomycin concurrent with catheter insertion was associated with a decreased incidence of CVC BSI, howeverconcerns regarding the emergence of vancomycin-resistant organisms preclude support of its use as a prophylactic agent.

Late follow-up and functional outcome after traumatic reproductive tract injuries in women.

The aim of this study was to assess female reproductive tract injuries and late effects on sexual and reproductive function. This was a review of women presenting to a Level I trauma center with reproductive tract injuries over 12 years. Thirty-one women (average age, 30 years) were divided into coital (19) and noncoital (12) injury groups. One-third of coital trauma presented late, one-fourth was abuse related, and seven women presented in shock. All had vaginal lacerations, and 15 required repair. Follow-up in 6 of 19 (32%) women averaged 4.5 years. Noncoital injuries resulted primarily from vehicular trauma, and two-thirds had associated abdominal injuries. Interventions included: vaginal laceration irrigation/repair (4), salpingectomy (2), ovariectomy (2), repair uterine perforation (1), and emergency cesarean section (2). The average Injury Severity Score was 25, with two deaths. Follow-up in 6 of 10 (60%) survivors averaged 6.1 years. The combined group has had seven subsequent pregnancies, and two women have minor dyspareunia after pelvic fracture. Women with coital injuries may develop shock, requiring rapid resuscitation and operative repair. Noncoital injuries are often associated with multiple severe injuries and require operative intervention. Late sequelae are minimal in both groups, and even severe injuries do not preclude normal pregnancy and sexual function.

The presence of Müllerian inhibiting substance binding sites in human sperm.

PURPOSE: The binding of Müllerian inhibiting substance (MIS) to human sperm was investigated using immunohistological techniques. MATERIALS AND METHODS: Sperm from 5 normal donors and 6 subfertile men were studied. Whole or thin-sectioned sperm were incubated without or with recombinant human MIS (0.5 microg./ml.). MIS binding was identified under light microscopy (LM) using rabbit anti-human MIS antibodies tagged with goat IgG-horseradish peroxidase and diaminobenzidine as substrate, or by scanning and transmission electron microscopy (SEM and TEM) using gold labeled goat IgG. Intracellular MIS binding in sperm sections was examined by TEM. Antibodies were omitted in the controls. RESULTS: Under LM, DAB staining was present on sperm incubated with or without MIS and absent on controls. Using SEM, gold particles were found primarily on the surfaces of the sperm head with less binding to the tail. With TEM, the clustering of gold particles around the head of sperm represents MIS binding, but very few or no gold particles could be found associated with the sperm tail. MIS binding was also found associated with intracellular structures, but only within the head of the sperm. Overall, less gold particle binding was present in subfertile compared with normal sperm. CONCLUSIONS: These results suggest that MIS is bound to the sperm surface and sperm from normally fertile men have increased MIS binding. The function of MIS in sperm is unknown, but the presence of MIS binding suggests a direct role(s) in sperm function.

Practice patterns of pediatric surgeons caring for stable patients with traumatic solid organ injury.

BACKGROUND: Managed care financing has resulted in pressure to decrease hospital days and lower per diem costs. This influence may ultimately affect nonoperative management of blunt solid organ injuries in children (spleen, liver, kidneys). METHODS: Pediatric surgeons caring for trauma patients were surveyed regarding current practice patterns. One survey was sent to a representative staff pediatric surgeon at each major children's hospital or children's unit involved in the care of the injured child in the United States. RESULTS: There were 87 responses to 117 surveys (75%). Relatively few children fail nonoperative management. For major management decisions, including radiographic study of choice; when to transfuse; and when to allow out of bed, home, and back to school, there was often a clear majority opinion of appropriate care. However, there was a wide variance in response for some questions. CONCLUSIONS: Surgical judgment must be individualized, but a low number of failures of nonoperative management is helpful in delineating safe practice guidelines. Surgeons using fewer resources than the norm may help delineate management schemes that are equally effective to more expensive care. Based on these responses a management protocol is recommended.

Müllerian-inhibiting substance in follicular fluid and serum: a comparison of patients with tubal factor infertility, polycystic ovary syndrome, and endometriosis.

OBJECTIVE: To determine Müllerian inhibiting substance (MIS) levels in follicular fluid (FF) and sera of IVF patients. DESIGN: Prospective study. SETTING: Fertility center. PATIENT(S): Sixty-six patients: 20 with tubal factor infertility, 17 with polycystic ovary syndrome (PCOS), and 29 with endometriosis. INTERVENTION(S): All patients underwent ovarian stimulation with hMG and/or FSH, as well as oocyte retrieval for IVF. MAIN OUTCOME MEASURE(S): Follicular fluid and serum MIS levels and oocyte fertilization rates. RESULT(S): Levels of MIS in FF and sera of PCOS patients were significantly higher than those in tubal factor patients: 7.01 +/- 1.52 versus 1.65 +/- 0.23 ng/mL (mean +/- SE) and 2.97 +/- 0.52 versus 0.92 +/- 0.19 ng/mL, respectively. In endometriosis patients, follicular fluid and serum MIS levels were not significantly different from those in tubal factor patients. In PCOS patients, the percentage of immature oocytes retrieved (17.9% +/- 5.0%) was significantly higher compared with tubal factor (1.5% +/- 1.0%) and endometriosis (9.2% +/- 2.3%) patients. The percentage of oocytes fertilize was significantly lower in PCOS patients (30.2% +/- 5.3%) compared with tubal factor (62.2% +/- 5.5%) and endometriosis (37.5% +/- 5.7%) patients. CONCLUSION(S): Women with PCOS had higher serum and follicular fluid MIS levels, a higher percentage of immature oocytes, and lower fertilization rates than women with endometriosis or pelvic adhesions.