Livebirth and utero-placental insufficiency in Papio hamadryas baboons with uterus angiosome perfused by bilateral utero-ovarian microsurgical anastomoses alone.

STUDY QUESTION: Can the baboon uterus support a gestation to livebirth with an angiosome using microsurgically anastomosed utero-ovarian vessels and lacking uterine arteries and veins? SUMMARY ANSWER: Our angiosome model allows healthy livebirth albeit with risk of fetal growth restriction and stillbirth. WHAT IS KNOWN ALREADY: Uterine transplant can provide livebirth in humans, but requires a living donor to undergo a prolonged laparotomy for hysterectomy. In an attempt to avoid the time-consuming dissection of the uterine vein, our group has previously shown maintenance of baboon uterine menstrual function after ligation of the uterine vein and after ligation of both the uterine artery and uterine vein. STUDY DESIGN, SIZE, DURATION: In a 19-month timespan, three baboons underwent laparotomy to surgically alter uterine perfusion, and pregnancy outcomes were monitored after spontaneous mating in a breeding colony. PARTICIPANTS/MATERIALS, SETTING, METHODS: Three nulligravid female Papio hamadryas baboons in a breeding colony underwent laparotomy to ligate uterine arteries and veins along with colpotomy and cervico-vaginal anastomosis. During the same surgery, the utero-ovarian arteries and veins were microsurgically transected and re-anastomosed to themselves. Intraoperative organ perfusion was confirmed with laser angiography. After a recovery period, monitoring of menstrual cycling via menstrual blood flow and sex-skin cycling occurred, as well as uterine viability via sonography and cervical biopsy. Each baboon was released to the breeding colony for spontaneous mating and pregnancies dated by menstrual calendar and compared with early ultrasound. Delivery outcomes were monitored in each including neonate weight and placental pathology. In the event of a stillbirth, the animal was returned to the breeding colony for repeat mating attempts. After achieving a livebirth, the maternal baboon was removed from the study. MAIN RESULTS AND THE ROLE OF CHANCE: Each baboon in the trial underwent successful surgery with all uteri demonstrating viability and return of menstrual function within 10 weeks of surgery. Pregnancies occurred within two menstrual cycles in breeding colony. Baboons one and two initially had vaginal breech stillbirths, both with appearance of placental insufficiency, and one with fetal growth restriction. Baboon three underwent scheduled cesarean delivery resulting in a normally grown livebirth. Baboon one had a subsequent pregnancy resulting in a livebirth via cesarean delivery. LIMITATIONS, REASONS FOR CAUTION: Stillbirth in two of four gestations, and fetal growth restriction in one of four, are the largest concerns in our perfusion model. It remains uncertain whether the stillbirths resulted from placental insufficiency, or birth trauma from breech deliveries. WIDER IMPLICATIONS OF THE FINDINGS: The success of two livebirths warrants further attempts at improving consistency of our proposed uterine angiosome. This may allow living uterine donors to undergo less-invasive and shorter donor hysterectomy procedures. STUDY FUNDING/COMPETING INTEREST(S): The study had no external sponsors, and was supported by the Cleveland Clinic Foundation. Some equipment was loaned without cost to the research team including a laser angiography system courtesy of Novadaq Technologies, Inc. (Missaugua, ON, Canada) and a surgical microscope courtesy of DB Surgical (Coral Springs, FL, USA). B.B., K.A., M.S., K.R., M.M., P.F.E., A.T. and T.F. have no conflicts of interest. M.L.S. and S.Z. report activity as consultants for Medtronic-Covidien, and S.Z. also is a consultant to Applied Medical.

Internet-based monitoring and benchmarking in ambulatory surgery centers.

BACKGROUND: Each year the number of surgical procedures performed on an outpatient basis increases, yet relatively little is known about assessing and improving quality of care in ambulatory surgery. Conventional methods for evaluating outcomes, which are based on assessment of inpatient services, are inadequate in the rapidly changing, geographically dispersed field of ambulatory surgery. Internet-based systems for improving outcomes and establishing benchmarks may be feasible and timely. METHODS: Eleven freestanding ambulatory surgery centers (ASCs) reported process and outcome data for 3,966 outpatient surgical procedures to an outcomes monitoring system (OMS), during a demonstration period from April 1997 to April 1999. ASCs downloaded software and protocol manuals from the OMS Web site. Centers securely submitted clinical information on perioperative process and outcome measures and postoperative patient telephone interviews. Feedback to centers ranged from current and historical rates of surgical and postsurgical complications to patient satisfaction and the adequacy of postsurgical pain relief. RESULTS: ASCs were able to successfully implement the data collection protocols and transmit data to the OMS. Data security efforts were successful in preventing the transmission of patient identifiers. Feedback reports to ASCs were used to institute changes in ASC staffing, patient care, and patient education, as well as for accreditation and marketing. The demonstration also pointed out shortcomings in the OMS, such as the need to simplify hardware and software installation as well as data collection and transfer methods, which have been addressed in subsequent OMS versions. DISCUSSION: Internet-based benchmarking for geographically dispersed outpatient health care facilities, such as ASCs, is feasible and likely to play a major role in this effort.

A dual diagnosis typology to improve diagnosis and treatment of dual disorder patients.

A dual diagnosis typology was developed with three subtypes. Type I is a primary psychiatric disorder with substance use only when psychiatrically symptomatic (self-medication). Type II is a primary substance use disorder with substance-induced psychiatric symptoms. Type III is psychiatric and substance use disorders of long duration that are co-occurring or present at different times. Type III is considered the "true" dual disorder state. This typology was found to be reliable and have consensual validity. It was used with a standardized interview and clinical interview plus questions designed to determine the subtype with patients in psychiatric and substance abuse outpatient programs and with state hospital inpatient dual disorder patients. The dual disorder subtypes found in the psychiatric outpatient programs were: Type I, 21%; Type II, 9%; and Type III, 70%. In the substance abuse programs were found: Type I, none; Type II, 37%; and Type III, 63%. The subtypes in the state psychiatric patients were: Type I, 14%; Type II, 47%; and Type III, 39%. This method was found to be relatively easy to apply; it also increased staff interest in the dual disorder population and improved differential diagnoses and targeted interventions.

Dual diagnosis subtypes in urban substance abuse and mental health clinics.

OBJECTIVES: This study sought to determine rates of dual disorders (psychiatric and substance use disorders) in a population of low-income inner-city outpatients, to compare the rates in outpatient mental health and substance abuse treatment settings, and to examine the clinical usefulness of classifying patients with dual disorders into three subtypes. METHODS: A total of 57 low-income urban residents receiving mental health treatment and 73 receiving substance abuse treatment were given semistructured clinical interviews to ascertain lifetime and concurrent DSM-III-R axis I disorders. Patients with dual disorders were classified into subtypes depending on whether their psychiatric or substance use disorder was caused by the comorbid disorder or whether both disorders existed independently. RESULTS: Eighty-three patients had a lifetime history of dual disorders: 34 patients (60 percent) in the mental health settings and 49 (67 percent) in substance abuse treatment. Among the 83 with dual disorders, more than half had experienced symptoms of both disorders within the past year. Each of the disorders was considered primary (that is, no indication was found that one was caused by the other) for 24 patients in the mental health settings (71 percent) and 31 in the substance abuse treatment settings (63 percent). CONCLUSIONS: In each type of treatment setting, nearly two-thirds of the patients met criteria for a lifetime diagnosis of a dual disorder. This high rate of comorbidity did not appear to be attributable to substance use causing psychiatric symptoms, or vice versa. The high rate suggests the need for greater integration of mental health and substance abuse treatment, regardless of setting.

Physician motivation, satisfaction and survival.

Physicians are working harder today and enjoying it less. What has happened to create such dissatisfaction among those in one of the most autonomous professions? What can be done to address the anger, fear and unhappiness? This article is an analysis of the factors influencing human motivation. Maslow's hierarchy of needs--physiological, safety/security, social/affiliation, esteem and self-actualization--is used to suggest ways physicians can satisfy their needs in turbulent financial and professional times.

Treating alcoholism: an age-specific intervention that works for older patients.

Alcoholism occurs in 10 to 15% of the population over age 65 and may be difficult to diagnose. The diagnosis is based on a history aimed at detecting behavioral problems associated with drinking, administering an in-office screening instrument, and conducting tests of liver function and/or mean corpuscular volume. The most effective treatment approach in this population focuses on the stresses of aging and co-existing depression, rather than on alcohol use itself. This approach has been found equally effective in long-standing alcoholics and those who develop a drinking problem in late life. Generally, older alcoholics are very responsive to treatment.

Protracted Lhermitte's sign following head and neck irradiation.

Lhermitte's sign is a rare complication of head and neck irradiation involving the delivery of dose to the cervical spinal cord. Although uncommon, symptoms of lightning-like electric sensations spreading into both arms, down the dorsal spine, and into both legs on neck flexion following head and neck irradiation, causes great concern in both the patient and the physician. This spontaneously reversible phenomenon is important for the otolaryngologist and radiation oncologist to recognize and discuss. A particularly severe and protracted case of Lhermitte's sign involving a patient recently completing a radical course of radiation for nasopharyngeal carcinoma is described in detail, including a review of the literature surrounding the cause and management of this condition.

Alcoholism in the elderly. A serious but solvable problem.

Alcoholism is a more common problem in the elderly than has been recognized. Manifestations are more subtle than in younger alcoholics, and problems are primarily social rather than medical. Treatment approaches directed at the psychosocial stresses associated with aging are the most successful. The principles of the therapeutic community have also been effective in eliminating alcoholism and other behavioral disorders in elderly alcoholics.

The pigmented portio: benign lentigo of the uterine cervix.

The first case of benign lentigo of the uterine cervix is reported, providing further evidence that the cervix is able to form the entire spectrum of melanocytic lesions known to occur in the skin. Review of the literature reveals 19 cases of primary malignant melanoma of the cervix and 30 cases of blue nevus. The reported case offers support that benign lentigines may play a role as premalignant lesions of malignant melanoma not only in the skin, but aldo in mucous membranes.

Alcoholism and cerebral atrophy: a study of 50 patients with CT scan and psychologic testing.

A study of 50 alcoholic patients was carried out with CT scans of their brains and psychologic testing. These patients were alcohol and drug free, and without neurologic or psychiatric disorders at the time of the examinations. Fifty-eight percent of the patients had cerebral atrophy. There was no correlation between the results of the psychologic testing and cerebral atrophy. The only factor that correlated to a significant degree with cerebral atrophy was the duration of problem drinking. Only the mean duration of problem drinking was statistically significantly longer in the patients with cerebral atrophy compared to those patients with normal CT scans. Implications of this finding of high prevalence of cerebral atrophy in alcoholics is discussed.

Diagnosis and treatment of the elderly alcoholic.

Treatment interventions will be much more effective when delivered through facilities serving the aged, such as senior citizen programs, outpatient, geriatric, medical or psychiatric programs, nursing homes, or home-care programs. It is unlikely that significant numbers of elderly will be willing to go to alcoholism programs to deal with their problem drinking.

Sociopsychiatric perspectives on Jewish alcohol abuse: implications for the prevention of alcoholism.

Alcoholism is a major problem in our society and it is an increasing problem among American Jews. The sociocultural attitudes that equates Jewish identity with sobriety in contrast to drunkenness among non-Jews seems the major factor that accounts for the low rate of alcoholism among Jews. Alcohol problems increase when Jews lose their Jewish identity through less involvement with traditional religious practices, or in situations where it is difficult or impossible to maintain a Jewish identification such as in the military or in college, or when Jews live in a society where the dominant groups are not prone to drunkenness as in North Africa or Yemen. The Jewish experience with alcohol can be applied along with techniques designed to reduce the per capita consumption of alcohol as a means to prevent the development of alcoholism in our society. Recognition and treatment of alcoholism in Jews may be more difficult because of the severe stigma attached to alcoholism, but educating staff of social agencies and rabbis about alcoholism, and opening the doors of synagogues to AA meetings may lessen this stigma and help Jews who develop drinking problems go for treatment early in the course of their illness.