Ruptured ovarian cystic teratoma in pregnancy with diffuse peritoneal reaction mimicking advanced ovarian malignancy: a case report.

INTRODUCTION: This case illustrates the unusual complication of granulomatous peritonitis following rupture of a dermoid cyst in pregnancy resembling disseminated ovarian carcinoma. To the best of the authors' knowledge, this is the first report of this complication during advanced pregnancy in the literature. CASE PRESENTATION: A dermoid cyst ruptured during surgical removal in the second trimester of pregnancy in a 27-year-old primigravida. Postoperatively the patient suffered pulmonary embolism and leakage of sebaceous material through the abdominal wound. She gradually developed significant abdominal distension, gastrointestinal symptoms and lost more than 8 kg of weight in the 12 weeks postoperatively. The baby was delivered at 31 weeks by a technically challenging caesarean section owing to severe dense adhesions obscuring the uterus. Bowel resection was performed for suspected malignant infiltration and adhesion causing obstruction. She had a protracted convalescence with an ileostomy and mucus fistula. Histology confirmed granulation without malignancy. One year following the surgical treatment, she had recovered well and was planning her next pregnancy. CONCLUSION: Although granulomatous peritonitis following rupture of a dermoid cyst is very rare, awareness is the key to diagnosis and appropriate management. Per-operative frozen section may be helpful.

First trimester threatened miscarriage treatment with human chorionic gonadotrophins: a randomised controlled trial.

OBJECTIVE: To determine whether administration of exogenous human chorionic gonadotrophin (hCG) treatment improve the pregnancy outcome in first trimester threatened miscarriages. DESIGN: A prospective, double blind, randomised, placebo-controlled trial. SETTING: The Early Pregnancy Assessment Unit, Royal Bolton Hospital, Bolton, United Kingdom. POPULATION: One hundred and eighty-three women with vaginal bleeding and a viable fetus seen on ultrasound scan (USS) in the first 12 weeks of pregnancy. METHODS: The patients were randomised to receive either hCG or placebo treatment until 14 weeks of gestation. MAIN OUTCOME MEASURES: The primary objective of the trial was to determine the miscarriage rate in the hCG arm compared from the placebo arm. RESULTS: Of the 183 cases, 87 were randomised to treatment with hCG while 96 were randomised to receive a placebo. Forty-seven (25%) did not comply with the study protocol. The mean [SD] gestational age at presentation was 7 [1.33] weeks. The mean [SD] age of women in study was 27 [5] years in the placebo and 28 [5] in the hCG group. The mean body mass index (kg/m(2)) was 25 [5] in the study. The number of patients actively bleeding per vaginum at presentation was 85 (93%) in placebo group and 79 (96%) in the hCG group. The median number of hCG or placebo injections for both groups was 7. Ten women (11%) in the placebo group proceeded to have a complete miscarriage, as did 10 women (12%) in the hCG group, relative risk (RR) [95% confidence interval (CI)] of 1.1 (0.63-1.6). CONCLUSION: Our study showed no evidence of a difference in the outcome of threatened miscarriages when treated with hCG in the first trimester, this may be because our study sample size was small and follow up was suboptimal. A large, randomised, multicentre trial is still needed to establish the usefulness of hCG treatment in cases of threatened miscarriage.

Sub-aponeurotic fluid collections in infancy.

AIM: To describe the radiological features and natural history of sub-aponeurotic fluid collections presenting after the neonatal period. MATERIALS AND METHODS: All cases of sub-aponeurotic scalp fluid collection presenting to the radiology department between June 1996 and June 2000 were reviewed. Note was made of the birth history, the radiographic and ultrasound features and the natural history (including any treatment) of the collection. RESULTS: Seven cases of sub-aponeurotic fluid collections were identified. There were six infants who presented 3.5-18 weeks (mean nine weeks) after delivery, four of whom had had ventouse-assisted delivery. The last case was in a seven-year-old child who presented one month after minor head trauma. Clinical examination revealed non-tender, soft, mobile and fluctuant scalp swellings in all patients. Ultrasound identified sonolucent fluid collections of between 5 and 24 mm depth in the sub-aponeurotic space. No skull fractures were identified. Six patients were treated conservatively and one had fluid aspirated and a compression bandage applied. All cases resolved 2-24 weeks after diagnosis and there were no long-term sequelae. CONCLUSION: Sub-aponeurotic scalp collections presenting after the neonatal period are usually associated with ventouse-assisted delivery ultrasound is useful for diagnosis. The condition is benign and resolution occurs with conservative treatment.

In-vitro visualization of biopsy needles with ultrasound: a comparative study of standard and echogenic needles using an ultrasound phantom.

AIM: To demonstrate the circumstances where echogenically enhanced biopsy needles confer an increase in visualization during ultrasound-guided biopsy using an in-vitro experiment. MATERIALS AND METHODS: An experiment using both standard and echogenically enhanced needles was conducted in a purpose built interventional phantom. The needle tip echogenicity and shaft visualization was recorded at different angles (20 and 60 degrees ) between the ultrasound probe and needle. The needle tip echogenicity was also recorded in four different angles of bevel rotation. The experiment was performed using a total of 18 different needles of 18 and 20 gauge. RESULTS: The experiment confirmed some previous findings. The needle was better visualised at an angle of approximately 60 degrees to the probe. The needle tip was optimally visualized with the bevel facing the transducer or 180 degrees to it. Needle tip movement improved conspicuity. Using an optimal angle of approach (60 degrees ) the use of an echogenic needle did not confer any increase in conspicuity. If the transducer to needle angle was suboptimal (20 degrees ) then there was increased visualization of some echogenically enhanced needles. CONCLUSION: Optimisation of the conditions prior to ultrasound-guided needle biopsy will increase the visualization of the chosen device thus aiding the interventionalist. Needle gauge, bevel position, movement of the needle and the probe to needle angle all affect conspicuity. Needle coating or roughening does not improve tip visualization if the angle between the needle and probe can be optimized (60 degrees ). In unfavourable situations when the angle is suboptimal (20 degrees ), we have shown that echogenic enhancement of the needle tip can make it more visible.

Uterine exteriorisation at caesarean section: influence on maternal morbidity.

OBJECTIVE: To compare the influence on caesarean section morbidity of uterine exteriorisation or in situ repair. DESIGN: Randomised controlled trial. SETTING: Princess Anne Maternity Unit of the Royal Bolton Hospital, UK. POPULATION: One hundred and ninety-four women undergoing delivery by caesarean section. METHODS: Two intra-operative readings of arterial pulse rate, mean arterial blood pressure, and arterial haemoglobin oxygen saturation were obtained. Pre-operative and day-3 haemoglobin concentrations were determined. Intra- and post-operative complications, puerperal pain scores, and febrile and infectious morbidity were assessed. A postal questionnaire was used to assess morbidity six weeks after delivery. MAIN OUTCOME MEASURES: Intra-operative changes in pulse rate, mean arterial blood pressure and oxygen saturation; peri-operative changes in haemoglobin concentration; incidence of intraoperative vomiting, pain, intra- and post-operative complications, and febrile and infectious morbidity; immediate and late puerperal pain scores; satisfaction with the operation. RESULTS: No clinically significant differences between uterine exteriorisation and in situ repair were found in pulse rate, mean arterial pressure, oxygen saturation and haemoglobin changes. Likewise, the incidence of vomiting and pain was similar. Vomiting occurred in 10% of all the women, and 57% of all pain complaints occurred at the initial skin incision. There was a trend towards higher immediate and late pain scores in the exteriorisation group, reaching statistical significance on day 3. Overall, pain scores averaged 6/10 on day 1 despite patient-controlled analgesia, and three-quarters of all women reported persisting pain on day 42. Intra- and post-operative complications, febrile and infectious morbidity, and duration of hospital stay were similar in both groups. CONCLUSIONS: We have demonstrated that uterine exteriorisation and in situ repair have similar effects on peri-operative caesarean section morbidity. Intra-operative pain reflected adequacy of anaesthesia, while vomiting reflected adequacy of pre-operative preparation of patients. Exteriorising the uterus at caesarean section is a valid option.

Munchausen's syndrome in obstetrics and gynecology: a review.

Nineteen review articles and case reports were identified and reviewed through August 1996 in Index Medicus, MEDLINE (English and foreign language), conference abstracts, and bibliographies from major articles, textbooks and reviews, to review Munchausen's syndrome in obstetrics and gynecology. In these 19 articles, 30 reported cases of the syndrome were identified in obstetric and gynecological patients. This survey found that the presentation varied, diagnosis was difficult, treatment was unclear, and the economic burden was enormous. Increasingly, this syndrome is becoming an important clinical entity in the specialty, and requires a high index of suspicion to improve detection and optimize treatment.

Effect of hemoglobin solution on the response of intracranial and subcutaneous 9L tumors to antitumor alkylating agents.

The 9L gliosarcoma growing subcutaneously in the hind leg of the Fisher 344 rat contains major areas of severe (< 5 mmHg) hypoxia, making up about 49% of the tumor. Intravenous administration of an ultrapurified polymerized bovine hemoglobin solution (8 ml/kg) along with normal air breathing reduces the percentage of severe hypoxia to about 24% and increases oxygenation throughout the tumor. Coadministration of the hemoglobin solution increased the tumor growth delay of subcutaneously implanted 9L tumors treated with carmustine (BCNU), cyclophosphamide, or ifosfamide but did not significantly change the tumor growth delay produced by cisplatin (CDDP). Coadministration of the hemoglobin solution with each of the four antitumor alkylating agents resulted in a near doubling of the percentage of increase in life span in animals bearing intracranial tumors treated with the combination as compared with animals treated with the drugs alone. Increases in serum blood urea nitrogen (BUN) and creatinine levels in treated animals returned to normal by 11 days posttreatment. Major changes in liver enzymes occurred with the combination of cyclophosphamide and the hemoglobin solution at 4 days posttreatment; however, these values returned to the levels in the untreated control animals within 1 week thereafter. These results indicate that further exploration of the use of hemoglobin solutions in cancer therapy is warranted.

Effect of a bovine hemoglobin preparation (SBHS) on the response of two murine solid tumors to radiation therapy or chemotherapeutic alkylating agents.

When tested in mice bearing the Lewis lung tumor with 2, 3, or 4 Gy daily for 5 days, SBHS produced a dose-modifying factor of 1.6 that was increased to 2.1 with carbogen. The addition of SBHS (1.32 gm protein/kg) to treatment with melphalan (MEL) resulted in a 2.2-fold increase in the tumor growth delay (TGD). The combination of SBHS with carbogen (6 h) produced a 3.6-fold increase in TGD compared with MEL alone. The addition of SBHS to treatment with cyclophosphamide (CTX) resulted in a 2-fold increase in the TGD. However, the combination of SBHS and carbogen was much more effective resulting in a 4.6-fold increase in TGD. There was a 1.3-fold increase in TGD with SBHS and CDDP compared with CDDP alone. The combination of SBHS and carbogen was a more effective addition to CDDP resulting in a 1.9-fold increase in TGD. The addition of SBHS to treatment with BCNU increased the TGD produced by BCNU by 1.5-fold. The combination of SBHS/BCNU and carbogen resulted in a 2.3-fold increase in TGD over that obtained with BCNU alone.

Effect of a bovine hemoglobin preparation on the response of the FSaIIC fibrosarcoma to chemotherapeutic alkylating agents.

Polymerized bovine hemoglobin solutions (PBHS) are being actively investigated as blood substitutes. In studies analogous to those we conducted with perfluorochemical emulsions/carbogen, we have examined the effect of PBHS +/- carbogen (95% O2, 5% CO2) breathing on the antitumor efficacy of melphalan, cyclophosphamide, N,N'-bis(2-chloroethyl)-N-nitrosourea (BCNU) and cis-diamminedichloroplatinum(II) (cis-platin). The tumor growth delay of the FSaIIC fibrosarcoma treated with melphalan (10 mg/kg), cyclophosphamide (150 mg/kg), cisplatin (10 mg/kg) and BCNU (15 mg/kg) was increased about 2.2-fold, about 2.1-fold, about 1.2-fold and about 1.5-fold, respectively, when PBHS (12 mg/kg) was administered i.v. before each drug was injected i.p. The tumor growth delay produced by each drug was further increased when carbogen breathing for 6 h was allowed after administration of the drug and PBHS. In tumor cell survival experiments 24 h following drug treatment, the addition of PBHS increased the tumor cell killing of both melphalan and cyclophosphamide by about a factor of 10 at the lowest doses of each drug tested (10 mg/kg for melphalan and 100 mg/kg for cyclophosphamide) compared to the drug alone. However, at higher drug doses this effect was lost. The toxicity of each antitumor agent toward bone marrow (granulocyte/macrophage-colony-forming units) was increased 2- to 3-fold by the combined treatment. These results suggest that use of PBHS +/- carbogen breathing may add significantly to the efficacy of antitumor alkylating agents, however, the in vivo/in vitro data suggest that there will be increased bone marrow toxicity with this approach. This needs to be taken into account in the design of clinical trials.

Effect of oxygen level on the enhancement of tumor response to radiation by perfluorochemical emulsions or a bovine hemoglobin preparation.

Attempts to correct tumor hypoxia with oxygen-carrying solutions have used high concentrations of inspired oxygen (FiO2 100% or 95%). In the clinic, however, obtaining such high levels of FiO2 using mask ventilation in older patients or in children may be difficult. Since lower levels of FiO2 had not been previously tested, we examined the antitumor efficacy of FiO2 levels of 65, 85, and 95% breathed for 1 hr prior to and during irradiation used with the concentrated perfluorochemical emulsion F44E, the less concentrated emulsion, Fluosol-DA, or a new preparation consisting of purified bovine hemoglobin solution, PBHS. When tested in mice bearing the Lewis lung carcinoma with 2, 3, or 4 Gy daily for 5 days, daily Fluosol-DA produced only a small increase in the slope of the tumor growth delay versus irradiation alone, when used with 85% FiO2 (dose modifying factor [DMF] 1.3), but produced a DMF of 2.1 with 95% FiO2. Various concentrations of F44E (2, 4, or 8 g PFC/kg) each required a 95% FiO2 for full effect but the 8 g/kg dose had a discernable effect with an FiO2 of 65% and 85% (DMF 1.25 and 1.30, respectively). For PBHS, in contrast, a DMF of 1.6 was observed at 20% FiO2, but surprisingly this increased further to 2.1 with 95% FiO2. Further investigations of PBHS with irradiation demonstrated that daily administration of PBHS (12 ml/kg) 1 hr before single Xray fractions of 5, 10, 15, or 20 Gy with 20% FiO2 resulted in a DMF of 1.6-1.7 in the FSaIIC fibrosarcoma compared with irradiation alone when ascertained by tumor cell excision assay. These results indicate that to achieve maximum antitumor benefit with these oxygen-carrying solutions with radiation therapy, care must be taken to insure that FiO2 levels near 100% are achieved.

Moderate caloric restriction delays cataract formation in the Emory mouse.

Eye lens senile cataract is a major cause of blindness, affecting the elderly in particular. The etiology of the disorder has been elusive, and attempts to delay the onset of senile cataracts have been unsuccessful. The need for more information is underscored by epidemiologists who estimate that the ability to delay cataract formation in humans by only 10 years would eliminate the need for 50% of the cataract extractions performed annually in the United States. The Emory mouse provides the best model for human senile cataracts. Feeding Emory mice a diet that was restricted in calories by approximately 21% delayed the onset of cataracts. This is the first study that demonstrates in vivo the delay of senile-type cataracts. In these animals, aging and cataracts are associated with diverse changes in the proportion of various proteins (particularly 21, 22, 31-34 kDa) and with transformation of proteins from a soluble to an insoluble state. In advanced cataracts, there is a loss of total protein. Within a cataract grade, there is no difference between restricted and nonrestricted animals in relative proportion of specific lens proteins or in amounts of total or soluble proteins. The transition from a clear to cataractous lens appears when the soluble-to-total protein ratio falls below about 0.58. The exclusive use of gamma-crystallin as an indicator of lens viability is questioned. To the extent that cataract formation is due to lens protein oxidation and/or an inability to proteolytically remove damaged protein, it would appear that caloric restriction results in enhanced protection against lens oxidative stress or in prolonged proteolytic function.

Effect of anthelminthic treatment on the immune response of mice.

Immunologic function was tested both in vivo and in vitro in mice undergoing prophylactic anthelminthic therapy with three agents to assess whether these drugs affected immune responses. This study was performed because investigators often are concerned about the effect of drug treatment on the induction of specific immune responses. While helminthic infestation is recognized as deleterious to the host, it is unclear whether anthelminthic treatment might be immunosuppressive. The effects of piperazine or trichlorphon administered to drinking water or fenbendazole administered in feed were insignificant in BALB/c mice. The induction of allospecific cytolytic T lymphocytes (CTLs) in vitro, influenza specific memory T cells in vivo, influenza specific antibody secretion in vivo, or influenza-specific helper T cells and CTLs in vitro were examined. Results of this study indicate that anthelminthic treatments did not interfere with immune responses.

The influence of insemination timing and semen characteristics on the efficiency of a donor insemination program.

The analysis of accumulated data from conceptional and nonconceptional ovulatory menstrual cycles of patients undertaking artificial donor insemination has allowed some observations to be made on the practical aspects which may influence the efficiency of the program. The evidence suggests that with the use of preserved semen, accurate timing of insemination is essential, and that days 0 and +1 with respect to the luteinizing hormone surge appear to be advantageous as compared with closely related days. When the numbers of motile spermatozoa which were inseminated over a critical 4-day interval were analyzed, the results also suggested that improved conception rates occurred when larger numbers of active spermatozoa were used. A comparison was made between those patients who had been inseminated on a single occasion and those inseminated on more than one occasion during the periovulatory period. The results obtained from those cycles inseminated on a single occasion were inferior to those obtained from cycles inseminated more than once. Finally, some limited comparison is drawn between the established insemination programs of bovine husbandry and the relatively inefficient human experience. One explanation may lie in the wider spectrum of donor semen desirable for the human programs.