Ovarian cysts during pregnancy: dilemmas in diagnosis and management.

With routine obstetric ultrasound examinations, ovarian cysts are now more commonly diagnosed during pregnancy and their management is still a challenging clinical issue among obstetricians. The aim of this paper is to review the different management options of ovarian cysts detected during pregnancy, and it highlights the emergence of laparoscopic technique as a valuable therapeutic tool in these conditions. The review shows that conservative management and ultrasound follow-up is sufficient for the majority of cases of ovarian cysts during pregnancy. It also discusses the limitations of tumour markers during pregnancy, and the controversy around ultrasound-guided aspiration procedures. Emerging evidence suggests that if surgery is necessary, then it is preferable to perform an elective laparoscopic procedure at 16 - 23 weeks' gestation. It is time to consider establishing a UK registry to monitor the treatment offered to those women and to develop national guidelines to help in the management of this controversial issue.

Transdermal oestrogen for treatment of severe postnatal depression.

BACKGROUND: Postnatal depression can have long-term adverse consequences for the mother, for the marital relationship, and for the infant's psychological development. Such depressions can be severe and resistant to both support and counselling and to therapy with antidepressant drugs. We investigated the antidepressant efficacy of oestrogen given transdermally. METHODS: In a double-blind, placebo-controlled study, 61 women with major depression, which began within 3 months of childbirth and persisted for up to 18 months postnatally, were allocated randomly active treatment (n=34; 3 months of transdermal 17 beta-oestradiol 200 micrograms daily alone, then 3 months with added cyclical dydrogesterone 10mg daily for 12 days each month) or placebo (n=27; placebo patches and tablets according to the same regimen). The women were assessed monthly by self-ratings of depressive symptoms on the Edinburgh postnatal depression scale (EPDS) and by clinical psychiatric interview (schedule for affective disorders and schizophrenia [SADS]-change scale). FINDINGS: On pretreatment assessments the women in both groups were severely depressed (mean EPDS score 21.8 [SD 3.0] active group, 21.3 [2.9] placebo group; SADS scores, 66.3 [11.4] and 64.3 [10.7]). During the first month of therapy the women receiving oestrogen improved rapidly, and to a significantly greater extent than controls (mean EPDS scores 13.3 [SD 5.7] vs 16.5 [5.3]. Patients receiving placebo also improved over time but, on average, their scores did not fall below the screening threshold for major depression for at least 4 months. The estimated overall treatment effect of oestrogen on the EPDS was 4.38 points (95% Cl 1.89-6.87). None of a range of other factors (age, psychiatric, obstetric and gynaecological history, severity and duration of current episode of depression, and concurrent antidepressant medication), influenced the response to oestrogen. INTERPRETATION: This study has shown that transdermal oestrogen is an effective treatment for postnatal depression. Further studies are required to establish the minimum effective dose and shortest necessary duration of treatment as well as the mechanism of antidepressant action of oestrogen.

Cough and stridor: who should investigate the patient?

Stridor is usually produced by obstruction in the upper airways. We present a case of stridor referred to the ENT Department in whom an endoscopic examination as far as the lower trachea showed no abnormality. A subsequent bronchoscopy in the Chest Department revealed a tumour in the right main bronchus.

Obstructive sleep apnoea syndrome presenting as lingual ulceration.

Two patients with obstructive sleep apnoea syndrome are reported where the initial presenting complaint was of lingual ulceration. This unusual presentation has not been reported previously. Both patients experienced frequent apnoeic episodes during sleep with a profound fall in the arterial oxygen saturation. It is postulated that the lingual ulceration resulted from repeated trauma to the tongue by the teeth as the patient made violent inspiratory efforts at the termination of an apnoeic episode. The diagnosis of sleep apnoea syndrome was based upon suggestive symptoms of snoring, morning fatigue and day-time somnolence plus a minimum of 15 apnoeic episodes per hour of sleep. The first-line investigations of this condition are available in all district general hospitals and a diagnosis of sleep apnoea syndrome obtained. Referral to a regional sleep study centre may be appropriate prior to the commencement of therapy. Management is predominantly medical, consisting of weight loss and the administration of nocturnal nasal continuous positive airways pressure.

High dose epirubicin chemotherapy in untreated poorer prognosis small cell lung cancer.

A single agent chemotherapy regimen, comprising epirubicin 120 mg m-2 iv at 21-day intervals for a maximum of six cycles was administered to 26 patients with intermediate or poor prognosis small cell lung cancer. Staging consisted of both conventional disease extent and prognostic guidelines based on laboratory parameters. The overall response rate was 57% which predominantly occurred among the intermediate prognosis group (14 of 17 patients), compared with only 1 of 9 patients in the poor prognosis category. Seven patients survived for at least 12 months, including one 3-year survivor (remains disease free). Chemotherapy toxicity was easily managed and chemoresponse was generally accompanied by an improvement in perceived performance rating. The study confirms the activity of epirubicin against small cell lung cancer and emphasizes the importance of patient selection within the spectrum of small cell lung cancer.

Apical pulmonary fibrosis in psoriasis.

Apical pulmonary fibrosis has been established as a non-articular complication of ankylosing spondylitis. Although psoriasis is frequently associated with arthropathy and spondylitis, there is only one previous report of apical fibrosis occurring in a patient with psoriasis. We report two patients with psoriasis complicated by apical pulmonary disease in whom extensive investigations were negative.

The effect of nifedipine on bronchial reactivity to inhaled histamine and methacholine: a comparative study in normal and asthmatic subjects.

The effect of pretreatment with nifedipine 20 mg sublingually on the bronchoconstrictor response to inhaled histamine and methacholine in asthmatic and normal subjects has been studied. For each agonist the provocation concentration required to produce a 15% fall in FEV1 (PC15) and a 35% fall in specific conductance (PC35) was determined. In the group of asthmatic subjects the responses to histamine were significantly attenuated by histamine, PC15 increasing from 0.29 mg/ml to 0.68 mg/ml (P less than 0.001) and PC35 increasing from 0.25 mg/ml to 0.58 mg/ml (P less than 0.001). Responses to methacholine showed less modification by nifedipine. PC15 increased from 0.23 mg/ml to 0.32 mg/ml (P less than 0.05). Changes in PC35 were not significant. In the group of normal subjects no attenuation of the response to methacholine was produced by nifedipine but significant increases of PC15 (P less than 0.002) and PC35 (P less than 0.005) were produced by the agent. The results are consistent with nifedipine exerting an effect principally on mediators dependent on external calcium sources for stimulus-contraction coupling in the airways. The magnitude of change in the histamine response of the two groups was similar, suggesting calcium dependent mechanisms are not involved in asthmatic hyper-responsiveness.

Life-threatening respiratory failure due to a previously undescribed myopathy.

The case of a young man with a previously undescribed myopathy associated with polydactyly is reported. Although both limb girdles were affected, the major effect of the disease was upon the respiratory muscles leading to his presentation with life-threatening respiratory failure. A further feature was pronounced stiffness of the vertebral column and limb girdles, similar in some respects to the 'rigid spine syndrome'. Muscle biopsy appearances were unique but showed some similarities to both nemaline myopathy and myotonic dystrophy. Ventilatory assistance at night using a rocking bed led to a marked improvement and has enabled the patient to return to full-time employment.

Re-expansion pulmonary oedema: a potentially serious complication of delayed diagnosis of pneumothorax.

Re-expansion pulmonary oedema may develop if diagnosis and treatment of pneumothorax are delayed. This condition may be fatal if inappropriately managed.

Cold air as a bronchial provocation technique. Reproducibility and comparison with histamine and methacholine inhalation.

Bronchial provocation testing with cold air was carried out on 36 asthmatic and 13 normal subjects in order to assess the reproducibility and clinical relevance of the technique as a test of airways reactivity. Sixteen subjects underwent repeat testing after an interval of two to three weeks. Using a least squares linear regression analysis, the technique was highly reproducible, with a correlation of r = 0.93 (p less than 0.001). The 21 asthmatic subjects who had exercise-provoked symptoms required a significantly lower level of ventilation of cold air to produce a 35 percent drop in specific airways conductance (PD35) than did those who had no exercise-induced asthma (33.9 L min-1 vs 45.8 L min-1; p less than 0.02). Subjects requiring no regular treatment for their asthma had a geometric mean PD35 of 62.6 L min-1, significantly higher than those requiring inhaled therapy (44.9 L min-1; p less than 0.005). Subjects requiring oral in addition to inhaled treatment had the lowest PD35 (23.6 L min-1; p less than 0.02). Atopic status did not appear to influence the response. There was a strong correlation between the PD35 to cold air and to histamine (r = 0.92; p less than 0.001) and between the PD35 to cold air and to methacholine (r = 0.86; p less than 0.001). The three techniques of assessing bronchial reactivity were equally successful in separating the normal and asthmatic groups. The results indicate that cold air provocation may be reliably and reproducibly used to assess bronchial reactivity. The use of a naturally-occurring stimulus of asthma in all subjects has great potential as an investigational technique.

The influence of pretreatment with prostaglandin F2 alpha on bronchial sensitivity to inhaled histamine and methacholine in normal subjects.

The effect of pretreatment with prostaglandin F2 alpha (PGF2 alpha) on the bronchial sensitivity to histamine and methacholine has been studied in three groups of six normal subjects, and compared with the effect of citric acid aerosol as a non-specific stimulant of bronchial irritant receptors. Aerosols were generated by Wright's nebulizer and dose-response curves to histamine and methacholine constructed following preadministration of saline, prostaglandin F2 alpha or citric acid. Following prostaglandin F2 alpha pretreatment, the PC20 histamine fell from 12.9 mg/ml to 3.4 mg/ml (P less than 0.01), but the PC20 methacholine was unchanged. Citric acid was without effect. The results indicate that prostaglandin F2 alpha can increase bronchial sensitivity to inhaled histamine, possibly via a direct effect on the airway smooth muscle.