Computed tomography changes diagnosis, management and surgical planning of ankle fractures.

PURPOSE: To demonstrate how the use of adjunctive Computed Tomography (CT) can modify diagnosis, treatment options, and operative planning of ankle fractures in comparison with conventional radiographs (CR) in isolation. MATERIALS AND METHODS: A total of 53 patients diagnosed with an ankle fracture between 2011 and 2016, were assessed with CT and CR. Evaluations of the fractures using CR in isolation and CR combined with CT were compared using different readers. Fractures were assessed in terms of type, displacement, size, associated injuries, treatment, patient position and surgical planning. RESULTS: The medial malleolus fractures characteristics (posteromedial fragment and anterior colliculus), the presence of posterior malleolus fracture and its characteristics (displacement, size, posteromedial or posterolateral segment) (ps < 0.042), syndesmosis injury (p < 0.001), and the absence of deltoid ligament lesion (p < 0.001), were more evident with the combination of CT and radiographs. There was an increase in operative indication (p = 0.007), prone positioning (p = 0.002), posterior malleolus surgical treatment (p < 0.001), posterolateral approach for the lateral malleolus (p = 0.003), and syndesmosis fixation (p = 0.020) with the association of CT and CR, among all groups of expertise, with a high interobserver reliability (> 0.75). CONCLUSIONS: The CR may fail to demonstrate subtle lesions, such as posterior malleolus fractures and syndesmotic injuries. The CT evaluation increases the diagnostic precision and improves the quality of information the surgeon receives, what might positively affect patient care. LEVEL OF EVIDENCE III: Retrospective Comparative Study.

Effect of the subdose of human chorionic gonadotropin applied in the Hou Hai acupoint on ovulation induction in mares / [Efeito da subdose de gonadotrofina coriônica humana aplicada no acuponto Hou Hai sobre a indução da ovulação em éguas]

The objective of this study was to evaluate the effects of an hCG sub dose applied at the Hou Hai acupoint on corpus luteum (CL) quality and ovulation induction in mares. Fifteen crossbred mares were distributed in randomized blocks and used in three periods with each period employed as the blocking factor in three treatments: T1 = 1500 IU of hCG via intravenous (IV); T2 = 450 IU of hCG applied at the false acupoint (IV); and T3 = 450 IU of hCG applied at the Hou Hai acupoint. Mean diameter of the CL, serum concentration of progesterone (P4), vascularization of the pre-ovulatory follicle and CL were evaluated. Females administered 450 IU of hCG at the Hou Hai acupoint exhibited greater ovulation rates (33.33%) 48h after induction; The minimum number of colored pixel (NCP) of the pre-ovulatory follicle of control females was superior (40.33) to that of mares administered 450 IU of hCG IV at the false acupoint (36.84) and similar to that of those administered hCG at the Hou Hai acupoint (39.31). Further, moderately positive correlations were found between the CL diameter and the P4 concentration on D8 (P<0.05). IV administration of 450 IU of hCG or at the Hou Hai acupoint was efficient at inducing ovulation and ensuring the quality of CL in mares.(AU)

O objetivo foi avaliar os efeitos de uma subdose de hCG aplicada no acuponto Hou Hai na qualidade do corpo lúteo (CL) e na indução da ovulação em éguas. Quinze éguas mestiças foram distribuídas em blocos ao acaso, sendo o período utilizado como fator de blocagem, em: T1 = 1500 UI de hCG por via intravenosa (IV); T2 = 450 UI de hCG aplicado no falso acuponto (IV) e T3 = 450 UI de hCG aplicada no acuponto Hou Hai. Avaliou-se diâmetro médio do CL, concentração sérica de progesterona (P4), vascularização do folículo pré-ovulatório e do CL. As fêmeas que receberam 450 UI de hCG no acuponto Hou Hai apresentaram maiores taxas de ovulação (33,33%) 48h após a indução. O número de pixels coloridos (NPC) mínimo do folículo pré-ovulatório das fêmeas do grupo controle foi superior (40,33) ao das éguas que receberam 450 UI de hCG IV no falso acuponto (36,84) e semelhante ao das éguas que receberam hCG no acuponto Hou Hai (39,31); correlações moderadamente positivas foram encontradas entre o diâmetro do CL e a concentração de P4, ambos no D8 (P <0,05). A administração IV de 450 UI de hCG ou no acuponto Hou Hai foi eficiente na indução da ovulação e na garantia da qualidade do CL nas éguas.(AU)

Comparison of two surgical approaches for Laparoscopic Ovum Pick Up in Ewes / Comparação de duas abordagens cirúrgicas para aspiração folicular laparoscópica em ovelhas

The present study had as an aim to evaluate a right lateral access as an alternative method to laparoscopic ovum pick-up (LOPU) in sheep. Twenty-four Santa Ines ewes were randomly assigned in two groups with twelve animals each: RLD - positioned in right lateral decubitus, with 10º head-down tilt; and DD - positioned in dorsal decubitus with 35º head-down tilt. The following parameters were evaluated every 10 minutes during the procedure: total surgical time (ST), visualized follicles (VF), aspirated follicles (AF), recovered oocytes (RO), mean arterial pressure (MAP), heart rate (HR), respiratory rate (fR) and end tidal CO2 pressure (EtCO2). Pre and postoperative arterial hemogasometry parameters (PaO2, PaCO2, pH, CHCO3 and BE) were also evaluated; and serum fibrinogen levels (SFL) on postoperative period. The values of VF, AF, RO, fR, PaO2, pH, CHCO3, BE and SFL were similar between groups, although ST, HR, MAP, EtCO2 and PaCO2 were higher in LG. Regarding operative periods, PaO2 and pH were lower after surgery (PaO2: 79.1±16.4; 79.2±11.7mmHg; pH: 7.30±0.09; 7.32±0.08) in both groups when compared to preoperative (PaO2: 80.1±14.3; 83.4±10.5 mmHg; pH: 7.38±0.05; 7.39±0.05) while PaCO2 (43.6±4.6; 41.9±5.4mmHg) and CHCO3 (22.8±1.5; 22.7±3.0mmol/L) increased (PaCO2: 54.3±10.9; 46.9±6.3mmHg; CHCO3: 24.8±3.4; 24.4±2.7mmol/L) postoperative. This alternative decubitus presented is a viable procedure and did not differ in oocyte recovery rates in ewes. However, entails cardiorespiratory major alterations compared to conventional procedure, making its practical applicability limited.(AU)

O presente estudo teve como objetivo avaliar o acesso lateral direito como um método alternativo para a recuperação de oócitos por laparoscopia (LOPU) em ovelha. Vinte e quatro ovelhas Santa Inês foram distribuídas aleatoriamente em dois grupos com 12 animais: grupo RLD - posicionado em decúbito lateral direito, cefalodeclive com 10º de inclinação; grupo DD - posicionado em decúbito dorsal em cefalodeclive, inclinação de 35º. Foram avaliados, a cada 10 minutos, durante o procedimento cirúrgico: tempo total da cirurgia (ST), folículos visualizados (VF), folículos aspirados (AF), oócitos recuperados (RO), pressão arterial média (MAP), frequência cardíaca (FC), frequência respiratória (fR) e pressão final de CO2 (EtCO2). Também foram avaliados os parâmetros de hemogasometria arterial pré-operatória e pós-operatória (PaO2, PaCO2, pH, CHCO3 e BE), bem como os níveis séricos de fibrinogênio (SFL) no período pós-operatório. Os valores de VF, AF, RO, fR, PaO2, pH, CHCO3, BE e SFL foram semelhantes entre os grupos, embora ST, FC, MAP, EtCO2 e PaCO2 tenham sido maiores em RLD. Os parâmetros PaO2 e pH foram menores após a cirurgia (PaO2: 79,1±16,4; 79,2±11,7mmHg; pH: 7,30±0,09; 7,32±0,08) em ambos os grupos em relação ao momento pré-cirúrgico (PaO2: 80,1±14,3; 83,4±10,5mmHg; pH: 7,38±0,05; 7,39±0,05), enquanto PaCO2 (43,6±4.6; 41,9±5,4mmHg) e CHCO3 (22,8±1,5; 22,7±3.0mmol/L) aumentaram (PaCO2: 54,3±10,9; 46,9±6,3mmHg; CHCO3: 24,8±3,4; 24,4±2,7mmol/L) após a cirurgia. O decúbito lateral é uma alternativa viável para LOPU e não apresenta diferença para a taxa de recuperação oocitária em ovelhas. No entanto, promove alterações cardiorrespiratórias em comparação com o decúbito dorsal, tornando a sua aplicabilidade prática limitada.(AU)

Acoustic radiation force impulse (ARFI) elastography of adrenal glands in healthy adult dogs / Elastografia acoustic radiation force impulse (ARFI) das glândulas adrenais de cães adultos saudáveis

To describe the ARFI elastography in the evaluation of the adrenal glands in adult dogs, to evaluate the stiffness of adrenal parenchyma and to determine the qualitative and quantitative standards of the ARFI technique, which have not yet been described in veterinary medicine. Sixty adrenal glands from thirty healthy adult dogs were evaluated by B-mode and qualitative and quantitative ARFI elastography to assess the stiffness of healthy parenchyma and to determine the quality and quantity (shear velocity) standards of ARFI technique in body, cranial and caudal adrenal poles. Findings of ultrasonography evaluations were normal. Qualitative elastography showed that adrenal glands were not deformable and presented homogeneous middle-gray areas. The results of shear wave velocity were similar statically (P = 0.3087): 1) left adrenal - 1.42 m/s for cranial polar, 1.31 m/s for body region, and 1.71 m/s for caudal polar; 2) right adrenal - 1.42 m/s for cranial polar, 1.74 m/s for body region and 1.63 m/s for caudal pole. Quantitative and qualitative ARFI elastography of dogs' adrenal glands is feasible, well tolerated, easily implemented and may provide baseline data in the study of this structure to allow the use of ARFI.(AU)

Objetivou-se descrever a técnica de elastografia ARFI na avaliação das glândulas adrenais em cães adultos, visando avaliar a rigidez do parênquima adrenal saudável e determinar os padrões qualitativos e quantitativos (velocidade de cisalhamento) da técnica ARFI, ainda não descritos em medicina veterinária. Sessenta glândulas adrenais de 30 cães adultos saudáveis foram avaliadas pela ultrassonografia modo B e pela elastografia ARFI qualitativa e quantitativa para avaliar a rigidez do parênquima saudável e determinar a velocidade de cisalhamento e padrões qualitativos da ARFI no corpo, polos adrenais cranial e caudal. As características ultrassonográficas das glândulas foram normais. A elastografia qualitativa mostrou que glândulas adrenais não se apresentaram deformáveis e homogêneas (coloração cinza médio). Os resultados da velocidade de cisalhamento foram semelhantes (P = 0,3087): 1) adrenal esquerda ( 1,42m/s para polo cranial, 1,31m/s para corpo e 1,71m/s para polo caudal; 2) adrenal direita ( 1,42m/s para polo cranial, 1,74m/s para corpo e 1,63m/s para polo caudal. A elastografia quantitativa e qualitativa (ARFI) das glândulas adrenais de cães é uma ferramenta viável e facilmente implementada, podendo proporcionar valores padrão para o estudo dessa estrutura.(AU)

Levels and trends of smokeless tobacco use among youth in countries of the World Health Organization South-East Asia Region.

BACKGROUND: At least two rounds of the Global Youth Tobacco Survey (GYTS) have been completed in most of the countries in the World Health Organization South-East Asia region. Comparing findings from these two rounds provides trend data on smokeless tobacco (SLT) use for the first time. METHODS: This study uses GYTS data from Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste during 2006-2013. GYTS is a nationally representative survey of 13-15-year-old students using a consistent and standard protocol. Current SLT use is defined as using any kind of SLT products, such as chewing betel quid or nonbetel quid or snuffing any other products orally or through the nasal route, during the 30 days preceding the survey. Prevalence and 95% confidence intervals were computed using SAS/SUDAAN software. RESULTS: According to most recent GYTS data available in each country, the prevalence of current use of SLT among youth varied from 5.7% in Thailand to 23.2% in Bhutan; among boys, from 7.1% in Bangladesh to 27.2% in Bhutan; and among girls, from 3.7% in Bangladesh to 19.8% in Bhutan. Prevalence of SLT was reported significantly higher among boys than girls in Bhutan (boys 27.2%; girls 19.8%), India (boys 11.1%; girls 6.0%), Maldives (boys 9.2%; girls 2.9%), Myanmar (boys 15.2%; girls 4.0%), and Sri Lanka (boys 13.0%; girls 4.1%). Prevalence of current SLT use increased in Bhutan from 9.4% in 2009 to 23.2% in 2013, and in Nepal from 6.1% in 2007 to 16.2% in 2011. CONCLUSION: The findings call for countries to implement corrective measures through strengthened policy and enforcement.

Effects of a pediatric emergency department febrile infant protocol on time to antibiotic therapy.

The purpose of this study was to examine the effect of an Emergency Department (ED) protocol to reduce time to antibiotic administration in the febrile infant less than 3 months of age with a rectal temperature > or =38.0 degrees C. We conducted a before-after study of a febrile infant quality improvement initiative in an urban pediatric ED with approximately 35,000 patient visits per year. Records of infants less than 3 months of age presenting with a rectal temperature > or =38.0 degrees C, who underwent a full septic work-up (blood, urine, and cerebrospinal fluid studies, and possibly chest radiography), were identified by using daily ED logs. This review was performed in the month before and then 12 months after institution of the "Septic Infant Work-up Sheet" and a set of interventions (Febrile Infant Protocol) designed to streamline care of the febrile infant and to reduce the time to antibiotic administration. Data were analyzed by using the Kaplan-Meier survival estimate and the log-rank test. Patient demographic characteristics and severity of illness were similar across months; however, ED process of care was significantly changed. Initial analysis revealed a median time to antibiotics of 142 min. Subsequent analysis after implementation of the Febrile Infant Protocol revealed a median time to antibiotics of 105 min. This represents an overall time reduction of 25% from time of presentation to antibiotic administration. In conclusion, a guideline-based ED febrile infant protocol changed clinical practice and improved time to antibiotics.

Foster parents of medically fragile children can improve their BLS scores: results of a demonstration project.

OBJECTIVES: 1) To assess performance and comfort level with cardiopulmonary resuscitation (CPR), foreign body removal (FBR), and seizure management in foster parents of medically fragile children; 2) To determine if the parents' performance and comfort levels increase with an individual teaching session with a medical professional to review CPR and FBR. METHODS: In this single cohort pilot study, 18 foster parents of medically fragile children were asked to rate their comfort level with pediatric CPR and FBR on a 5-point scale (1 = very uncomfortable, 5 = very comfortable). They then underwent five mock code scenarios and were evaluated using a 5-point scale (1 = poor performance, 5 = outstanding performance). A 6-month follow-up evaluation using similar scenarios was conducted. RESULTS: At visit 1, the percentage of parents demonstrating adequate performance of CPR, FBR, and seizure management was: 1) CPR: infant (78%); child (78%); 2) Foreign body removal: age <1 year (17%); age >1 year (65%); 3) Seizures (94%). At visit 2, performance improved in all areas, especially FBR, where the percentage of parents demonstrating adequate performance increased to 71% for children <1 year and 82% for children >1 year. As measured by the 5-point scales, CPR and FBR performance and parent comfort level with CPR improved significantly (Wilcoxon signed-ranks test, P < 0.004), but parent comfort level with FBR did not (P = 0.12). CONCLUSIONS: Based on this pilot study, foster parents of medically fragile children benefit from an individual teaching session by a medical professional. CPR instruction for this group of foster parents should include adequate review and assessment of foreign body removal procedures.

Neck extension and rotation in sudden infant death syndrome and other natural infant deaths.

It has been hypothesized that some cases of sudden infant death syndrome (SIDS) are a result of neck extension and/or rotation that causes vertebral artery (VA) compression and brain stem ischemia. There is a paucity of relevant literature on this topic. Therefore, our aim was to compare neck rotation and extension in SIDS and other natural infant deaths. Cases of SIDS and other natural infant deaths within the San Diego SIDS Research Project database were analyzed retrospectively with respect to neck and body position as reported by the trained, experienced scene investigators and/or the caretakers who discovered the infants. Information was used from 246 SIDS cases and 56 cases of other natural deaths. Simultaneous neck extension and rotation was not reported in either group. When data regarding neutral/flexed/extended position and rotation of the neck were combined, no significant differences were found between the two groups (P = 0.94); 40% of the SIDS cases and 41% of the other natural death cases were found with the neck either extended or rotated (odds ratio [OR] 0.97, [reference group = neck either neutral or flexed, and not rotated], 95% confidence interval [CI] 0.45, 2.11). There were also no significant differences between the groups when neck rotation and neck extension were analyzed independent of one another. Neck rotation among cases found in the prone position was common and was not significantly different between the two groups (49% of 146 SIDS cases, 58% of 24 other natural death cases, P = 0.38, OR 0.68, 95% CI 0.28, 1.62). Neck rotation among infants found in the supine position occurred one-third as often in the SIDS group (9% of 33 cases) as in the other natural death group (29% of 14 cases); however, the difference was not significant (P = 0.17; OR 0.25, 95% CI 0.05, 1.31). Although our analysis does not exclude VA compression and brain stem ischemia in some cases of SIDS, we found no evidence to affirm its importance. This study demonstrates the importance of meticulous scene descriptions, including neck position.

Intrathoracic petechiae in sudden infant death syndrome: relationship to face position when found.

Previous studies have not addressed the relationship of intrathoracic petechiae (IP) to the position of the face when a caretaker finds a victim of sudden infant death syndrome (SIDS). The aims of this retrospective study were to determine (1) the rate of the facedown position in SIDS (not to be confused with the prone body position), (2) if the facedown position occurred more frequently among SIDS victims with intrathoracic petechiae than those without petechiae, and (3) if the facedown position occurred more frequently among cases with more severe petechial hemorrhage of the thymus. We selected 199 SIDS cases from the San Diego SIDS Research Project database and grouped them as IP-present and IP-absent. Each case was analyzed with regard to the face position when found unresponsive or dead. Among these 199 cases, 37% were found face-down, which represents 51% of the 142 cases found prone. The two groups were similar with respect to age, sex, and rate of premature birth. Thirty-nine percent (39%) of the IP-present group and 9% of the IP-absent group were found in the facedown position (P = 0.057; 95% confidence interval for the difference = 0.3%, 40%). Cases were also grouped by severity of thymic petechiae and analyzed regarding face position. Neither age nor the facedown position was associated with greater severity of thymic petechiae. The wide confidence interval yielded by our analysis of IP limits our ability to clarify the precise pathophysiologic role of external oronasal obstruction in SIDS. While it remains possible that a subset of SIDS cases occur as a result of external obstruction, we are unable to generalize its importance. Internal airway obstruction and rebreathing with terminal gasping, both of which have been documented in sudden infant death, remain other possible scenarios leading to the production of IP.

Successful treatment of retrograde ejaculation with sperm recovered from bladder washings. A report of two cases.

BACKGROUND: Retrograde ejaculation causes < 2% of male infertility but is the leading cause of aspermia. The incidence of retrograde ejaculation is increasing due to the aggressiveness of modern urologic cancer surgery and an increase in diabetes mellitus. Generally, the only adverse effect is on fertility. Various approaches have been proposed for treatment, ranging from insemination with sperm-rich urine obtained after masturbation to intracytoplasmic sperm injection (ICSI). We used a protocol involving bladder washing. CASES: Case 1 involved a man with retrograde ejaculation secondary to a successful right orchiectomy and retroperitoneal lymph node dissection for stage B1 embryonal cell carcinoma. He was treated with bladder washing and intrauterine insemination. He fathered three children from six insemination cycles. Case 2 involved a man with idiopathic retrograde ejaculation and a wife with ovulatory dysfunction. He received treatment similar to that in case 1 and fathered one child from two insemination cycles. CONCLUSION: Larger studies need to be done specifically comparing treatments. Our method resulted in four normal infants in two couples over eight total insemination cycles and, taken together with other results from the literature, seems a good choice for clinicians who are treating retrograde ejaculation for the first time. We agree with others who have recommended that in vitro fertilization/ICSI not be the first step for treating the usual couples with retrograde ejaculation.

Laparoscopic removal of a perforated intrauterine device from the perirectal fat.

BACKGROUND: The intrauterine device (IUD) was a very common form of birth control in the United States. The most serious potential complication of IUD use is uterine perforation. Uterine perforation is common among women with "lost" IUDs and can cause severe morbidity and mortality and should be carefully managed. The recommended treatment is removal of the perforating IUD. This can usually be managed laparoscopically unless bowel perforation or other severe sepsis is present. METHODS: An intra-abdominal IUD was removed laparoscopically from the perirectal fat of a 49-year-old woman who had been diagnosed over 20 years earlier with an "expelled" IUD. CONCLUSIONS: It is important that the possibility of uterine perforation be considered in anyone who has had a diagnosis of an expelled IUD without actual confirmation that the IUD is no longer present in the body. In any woman who presents with pelvic pain and a history of a "lost" IUD, the surgeon should have a high index of suspicion and obtain radiological studies. It may be advisable to question women about possible IUD use when they present with pelvic pain of unknown origin.

The effect of valproic acid on blood loss in patients with cerebral palsy.

Valproic acid (VPA) is used in the treatment of seizure disorders often present in patients with cerebral palsy. The charts of 114 patients with cerebral palsy were reviewed to evaluate the effect of VPA on blood loss during spine surgery. Forty-one patients had seizure disorders. Of these, 18 were taking VPA as monotherapy (group III) and the remaining 23 patients were taking other antiseizure medications, including two taking VPA (group II). There was a significant increase in the number of patients with abnormal bleeding times and a significant difference (p < 0.001) in blood loss (ml/kg) in patients taking VPA as monotherapy (38.6 ml/kg vs. 30.0 ml/kg). There was also increased blood-product administration postoperatively in the VPA monotherapy patients. Physicians should be aware of this potential association between VPA use and increased blood loss. The routine laboratory tests of complete blood count, prothrombin time, and partial thromboplastin time will not adequately screen for the platelet-mediated effects of VPA.

Impact of lifestyle choices on female infertility.

OBJECTIVE: To inform physicians who are involved in the primary care of reproductive-age women of the specific relationships between lifestyle choices and infertility so that they can use this knowledge to educate their patients and encourage changes in behavior. STUDY DESIGN: A review of the relevant literature, performed via Medline search. RESULTS: Prevention of chlamydial and gonorrheal infections; maintenance of the proper body weight; increased individual awareness about the effects of age on fecundity; and reduced intake of caffeine, tobacco and alcohol are all possible avenues for primary prevention of infertility. CONCLUSION: Lifestyle choices can be made that influence the reproductive capability of women. It may be worthwhile for primary care physicians to use information on lifestyle to encourage their patients to improve their overall health while positively affecting their ability to reproduce.

Etiology of supracondylar humerus fractures.

The specific etiology of supracondylar humerus fractures in children is not well known. All supracondylar humerus fractures treated at Children's Hospital and Health Center, San Diego (CHSD) over an 8-year period (n = 391) were reviewed to determine specific information about the manner in which the injury occurred. Girls tended to sustain these fractures more often, and the nondominant arm was more often injured. Falls from a height accounted for 70% of the fractures. Children < or = 3 years old tended to fall off of household objects (beds, couches, other objects 3-6 feet high), and children 4 years and older tended to fall from playground equipment such as monkey bars, slides, and swings. Safety precautions should be implemented in homes of young children and at playgrounds to avoid these fractures.

Ice-cream truck-related injuries to children.

Few studies exist on the cause and nature of injuries to children from ice-cream truck-related accidents. We reviewed the medical records of 11 children with orthopedic injuries treated at Children's Hospital-San Diego from 1985 to 1995 for injuries in such accidents. Of nine children on their way to or from an ice-cream truck who were struck by an oncoming vehicle, all were girls; eight had pelvic or lower-extremity fractures. When ice-cream trucks park on the street, they pose a danger to children, because children are drawn to them, and the trucks' large size blocks the vision of oncoming drivers.

Gamete intrafallopian transfer. A cost-effective alternative to donor oocyte in vitro fertilization in women aged 40-42 years.

OBJECTIVE: To investigate whether gamete intrafallopian transfer (GIFT) may be a cost-effective alternative to donor oocyte procedures in women 40 and older with good ovarian reserve. STUDY DESIGN: Retrospective review of records at an infertility clinic in a large multispecialty group practice. Twenty two consecutive women aged 40 and older underwent 24 stimulation cycles for laparoscopic GIFT procedures from 1988 to 1997. RESULTS: The mean GIFT cycle cost was $5,731. The delivery rate per stimulation cycle was 25.0%. The patients who gave birth were 40-42 years of age. The mean cost per delivered infant was $22,924. A previously reported value for mean cost per pregnancy for donor oocyte in vitro fertilization (IVF) was $30,457. Theoretical costs per delivery, generated from Society for Assisted Reproductive Technology outcome data for anonymous donor oocyte IVF in 1994 (delivery rate per transfer, 34.4%) for $8,000, $9,000 and $10,000 cycle costs were $23,256, $26,163 and $29,070, respectively. CONCLUSION: In women with good ovarian reserve, GIFT may be a cost-effective alternative to donor oocyte IVF at age 40-42.

Laparoscopic removal of virilizing hilar cell tumor in a postmenopausal patient.

A postmenopausal woman experienced rapidly progressing hirsutism and signs of virilization. Hormone evaluations showed markedly elevated serum testosterone levels and no evidence of excess cortisol or dehydroepiandrosterone sulfate production. A computerized tomographic scan of the adrenals and ovaries was normal, and transvaginal ultrasound revealed a left ovary with a maximum diameter of 3.2 cm. At outpatient laparoscopic bilateral oophorectomy, the left ovary had a benign, 2.5-cm Leydig cell tumor, hilar cell variant. Laparoscopy may be useful in the diagnosis and treatment of select cases of virilizing tumors of the ovary.

Improving the cost-to-benefit ratio of in-vitro fertilization.

In-vitro fertilization (IVF) has been criticized for being too costly to permit ready access to needy patients, either through their own funds or through those of third party providers. European groups have managed to offer these procedures at a fraction of the cost incurred by their United States counterparts by streamlining their protocols. Accordingly, we present our methods for reducing the cost of IVF. The main modification was made by performing the IVF procedures in the clinic under i.m. analgesia, avoiding the costs of a surgery suite and anaesthesia. In addition, donor, oocyte, micromanipulation, and cryopreservation services were not offered, reducing overall personnel and equipment costs. Overall costs were reduced from customary levels of $7,000--$11,000 in the United States to $3,409 per cycle initiated, while maintaining good ongoing/delivered pregnancy rates (30.0% versus 18.6% nationally) per cycle reaching aspiration. We conclude that, through the elimination of less necessary and/or utilized procedures, IVF may be performed in a more cost-effective manner while maintaining good success rates. For the patients who desire IVF services not offered under such a system, referral to a more specialized IVF center is appropriate.

High-frequency pressure-control ventilation with high positive end-expiratory pressure in children with acute respiratory distress syndrome.

OBJECTIVE: Animal models suggest that high-frequency ventilation with low tidal volumes and high positive end-expiratory pressure (PEEP) minimize secondary injury to the lung. We hypothesized that using a high-frequency pressure-control mode of ventilation with high PEEP in children with severe acute respiratory distress syndrome (ARDS) would be associated with improved survival. DESIGN: The study was a retrospective and prospective clinical study at a 24-bed tertiary care pediatric critical care unit. Fifty-three patients with severe ARDS were studied during a 37-month period, 30 prospectively and 23 retrospectively. Severe ARDS was defined as (1) rapid onset of severe bilateral infiltrates of noncardiac origin, (2) partial pressure of oxygen (arterial)/fraction of inspired oxygen less than 200 on PEEP of 6 cm H2O or more for 24 hours or longer, and (3) Murray disease severity score greater than 2.5. All patients meeting these criteria underwent ventilation in the pressure-control mode; the protocol for ventilation had the following general guidelines: (1) fraction of inspired oxygen limited to 0.5, (2) mean airway pressure titrated with PEEP to maintain arterial partial pressure of oxygen of 55 mm Hg or greater (7.3 kPa), (3) peak inspiratory pressure minimized to allow hypercapnia (arterial partial pressure of carbon dioxide, 45 to 60 mm Hg (6.0 to 8.0 kPa), and (4) ventilator rates of 40 to 120/min. Percutaneous thoracostomy and mediastinal tubes were placed for treatment of air leak. RESULTS: The survival rate was 89% (47/53) in children with severe ARDS. Nonsurvivors had significantly higher peak inspiratory pressures (75 vs 40 cm H2O, p = 0.0006), PEEP (23 vs 17 cm H2O, p = 0.0004), mean airway pressure (40 vs 28 cm H2O, p = 0.04), alveolar-arterial oxygen gradient (579 vs 540 mm Hg, p = 0.03), and oxygenation index (43 vs 19, p = 0.0008) than survivors. Air leak was present in 51% of patients; there was no difference in the incidence of air leak between survivors and nonsurvivors (p = 0.42). CONCLUSIONS: The high-frequency positive-pressure mode of ventilation was safe and was associated with an improved survival rate (89%) for children with severe ARDS. Limitation of both inspired oxygen and tidal volume, along with aggressive treatment of air leak, may have contributed to the improved survival rate.

Outpatient minilaparotomy ovarian cystectomy for benign teratomas in teenagers.

Benign cystic teratomas are the most common ovarian neoplasms in adolescents. An ovary-conserving method was developed for outpatient surgical removal of benign cystic teratomas by minilaparotomy in teenagers. The technique requires no specialized training, laser devices, or expensive disposable instrumentation. As a precaution, the first teenager in whom the technique was used was observed as an inpatient for 3 days. Following this, the method was used as an outpatient procedure in three further cases. No complications occurred in any of the four patients, and the mean operating time of 85 minutes (range, 60 to 95 minutes) was similar to the reported time for removal of benign cystic teratomas by laparotomy. Although a randomized controlled study with many more patients would be necessary for a definitive conclusion, considerable cost savings and reduction in morbidity over traditional laparotomy are suggested by this experience.