[Pulmonary embolism and right diaphragmatic paralysis: "one train can hide another"]. / Embolie pulmonaire et paralysie diaphragmatique droite "un train peut en cacher un autre".

The authors report the case of an 84 year old woman admitted for a mild pulmonary embolism associated with severe hypoxaemia. The association of a right diaphragmatic paralysis with renewed patency of a foramenovale and creation of a right-to-left shunt is probably an underestimated cause of refractory hypoxaemia.

[Myocardial infarction with normal coronary arteries: role of transesophageal echocardiography]. / Infarctus du myocarde à artères coronaires saines: place de l'échographie cardiaque transcesophagienne.

We report the case of 74 years-old female patient hospitalized for a ST+ acute coronary syndrome with normal coronary angiography. The association of a patent foramen ovale, a deep venous thrombosis and a pulmonary embolism led us to conclude the diagnosis of paradoxical coronary embolism. This case allows us to remind different etiologies to be considered in case of myocardial infarction with normal coronary arteries, and the interest of transesophageal echocardiography for the diagnosis of its etiology.

[Heparin-induced thrombocytopenia: a case of persistent thrombocytopenia]. / Thrombopénie induite à l'héparine: à propos d'une thtombopénine persistante.

Heparin-induced thrombocytopenia is rare. It should be considered if there is a reduction of at least 40% in the number of platelets and/or a level<100,000/mm3 in any patients who have received heparin in the previous 100 days. On stopping heparin, the rise in platelets is classically rapid, and normal levels are usually obtained in under 7 days. We report a case of heparin-induced thrombocytopenia, which was marked by a severe thrombocytopenia that only returned to normal 19 days after stopping heparin, in a patient treated initially with non-fractionated heparin for a pulmonary embolism secondary to an extensive deep venous thrombosis of the right lower limb.

Long-term efficacy and cost-effectiveness of polyethylene glycol 3350 plus electrolytes in chronic constipation: a retrospective study in a disabled population.

OBJECTIVES: The efficacy and safety of treatments for constipation in severely intellectually disabled patients and their associated cost-effectiveness are an under-investigated area of clinical practice. Aiming to address this, the objectives of the study were to evaluate the efficacy and tolerability of polyethylene glycol 3350 plus electrolytes (Movicol; PEG+E) by comparing clinical data collected before and after its introduction to a stable population of residents of a mental health care, long-stay institution. The study also attempted an economic evaluation of the use of PEG+E in this setting. RESEARCH DESIGN AND METHODS: This was a retrospective study of 54/66 severely intellectually and physically disabled residents of a specialist unit at La Milétrie University Hospital, Poitiers, France, who suffered regularly from constipation. A total of 54 residents were treated with PEG+E (1-3 sachets a day) for 24 months. The number of stools, episodes of diarrhoea (defined as frequent stools, not necessarily watery), body weights and blood biochemistry were recorded. Data were compared with those recorded during the 21 months preceding the introduction of PEG+E for 16/54 residents who had been treated regularly with a range of other interventions for the relief of constipation. The monthly use and costs of laxatives, enemas and suppositories was obtained from hospital pharmacy records, and the total hospital costs before and after the introduction of PEG+E treatment was calculated. RESULTS: The mean (+/- standard deviation) number of stools per patient per month was significantly greater following the introduction of PEG+E (24.9 +/- 6.3) compared to before its use (12.4 +/- 3.4) (p < 0.001). The mean (+/- standard deviation) monthly number of episodes of diarrhoea per patient before and after the introduction of PEG+E was 0.1 +/- 0.1 and 6.3 +/- 2.9, respectively (p < 0.001). Treatment with PEG+E was not associated with adverse effects on body weight or blood biochemistry values. Introduction of PEG+E and its increasing use reduced the total hospital medical ward expenditure on laxatives from 3788 to 1767 Euros per month. CONCLUSIONS: PEG+E is effective in the clinical management of constipation in an institutional setting. Furthermore, long-term intensive therapy with PEG+E was not associated with adverse effects on body weight or blood biochemistry values. Although the time periods over which the economic data and the efficacy and safety data were collected did not directly correspond, this study indicates that use of PEG+E in the management of constipation in people with severe intellectual disability may be cost-effective, reducing hospital laxative costs.

[Tako-tsubo syndrome and left ventricular obstruction: report of one case]. / Syndrome de tako-tsubo et obstruction intraventriculaire gauche: mécanisme de pérennisation? A propos d'un cas.

We report here the case of an 80 year old female suffering from Tako-tsubo syndrome diagnosed following type B aortic dissection, treated surgically with an aortic endoprosthesis. The recovery was marked by the secondary development of left intraventricular obstruction. Regression of the electrical and ultrasound anomalies was slow, taking 4 months of treatment with a beta-blocker. The intraventricular obstruction seemed to occupy a central role in this case, and we discuss the significance of this mechanical phenomenon in the pathophysiology of this syndrome.

Simple adnexal cysts in postmenopausal women: conservative management.

OBJECTIVE: To evaluate the expectant management of asymptomatic small, anechoic, simple ovarian cysts diagnosed by echography in postmenopausal women. To gain insight in the natural history of these cysts. METHOD: Thirty six postmenopausal women with asymptomatic ovarian cysts (from 1.5 to 5.0 cm) diagnosed by ultrasonography and with a CA 125 serum level within the normal range and a non-suspicious color Doppler were followed conservatively. Visits were scheduled at 8-10 weeks of the diagnosis, at 6-month intervals twice and annually thereafter. RESULTS: The follow-up period extended from 4 to 70 months with an average of 31.5 months. There were no cases of cyst enlargement. The cysts remained unchanged in 29 cases (80.5%), decreased in size in four cases (11.1%) and disappeared in three cases (8.3%). CONCLUSION: We think that the possibility of malignant transformation of one of these cysts is remote and the benefits of conservative management greatly outweighs its risks.

Expectant management of presumed ectopic pregnancies.

Thirteen patients with presumed diagnosis of unruptured ectopic pregnancy underwent expectant management. The diagnosis was based on the criteria of clinical stability, no intrauterine gestation sac by sonogram, and falling beta subunit human chorionic gonadotropin titer. The diagnosis also was based on no gross evidence of trophoblastic tissue on sharp curettage and alteration in uterotubal anatomy at laparoscopy. In these 13 patients, titers continued to drop and were below assay detectability (1.5 miu/ml) by 1 to 5 weeks. Only one patient required a laparotomy. Hysterosalpingograms in ten of the patients showed normal, patent tubes in seven. One patient had cornual occlusion and two showed a hydrosalpinx with spillage. A second laparoscopy in seven patients demonstrated normal tubes in all but one. At present, three patients have delivered term infants and two have had first trimester spontaneous abortions. These observations suggest that expectant management of tubal pregnancies is appropriate under rigidly controlled conditions.

Improving Falope-Ring application in laparoscopy training.

Laparoscopic Falope-Ring sterilization was performed by residents on 71 women. Immediately following application of the ring, methylene blue was injected through the cervix to assess tubal patency. Unilateral spillage of the dye was demonstrated in four patients (5.6%). In these instances a new ring was applied, or the tube was tied surgically. The high rate of tubal patency was attributed to the surgeons' inexperience. The findings suggest that the use of a patency test as an adjunct to sterilization with the Falope-Ring in training programs is likely to decrease the rate of surgical failures.

PIP: Gynecologist residents in training performed 71 laparoscopic Falope-Ring sterilizations under supervision, and effectiveness of the ligation was tested by dye passage. The operations were done with the KLI one-puncture laparoscope under general anesthesia, and methylene blue dye was introduced transcervically via the Rubin cannula used to stabilize the uterus. Patients ranged from 23-49 years, mean 29.8, parity 1-8, mean 23.7. Dye spilled out on one side in 4 cases, all with a ring verified as placed on the fallopian tube. Two instances of slow dye passage occurred with the ring 1.5-2.0 cm from the uterotubal junction. In one case the ring encircled only the serosa of an edematous tube, and in the other the ring was too distant. The only other complications were loss of 2 rings in the peritoneal cavity, application of a ring on the round ligament, later corrected and a cervical laceration requiring suturing. Since others have also reported higher failure rates of band laparoscopic sterilization early in physicians' experience, it is recommended that doctors in training use the dye patency test.

Tetanus complicating elective surgery. Two cases following female sterilization.

Two cases of fatal tetanus infection after female sterilization are presented. The possible sources of infection are discussed and the methods for prevention are evaluated. Active immunization before surgery is the ideal method; voluntary sterilization clinics could promote tetanus immunization and contribute to the improvement of the health of the population served.

Treatment of vaginal trichomoniasis. Single, 2-gram dose of metronidazole as compared with a seven-day course.

Although a single, 2-gm dose of metronidazole has been approved for the treatment of vaginal trichomoniasis, this regimen has not gained general acceptance. We compared the single, 2-gm dose versus the regimen of 250 mg administered three times daily for seven days. Two hundred sixty-three women with vaginal trichomoniasis were treated. One hundred seventy returned for follow-up. Of them, 96 received the single, 2-gm dose and 74 the seven-day treatment. The cure rates were 93.8% and 97.3%, respectively, and were not significantly different. These data compare favorably with those from previous studies. The side effects were minimal and occurred with greater frequency in the group receiving the single, 2-gm dose; nevertheless, the difference was not significant. We recommend the 2-gm regimen for the treatment of vaginal trichomoniasis because of its easy administration, better patient compliance and lower cost.

Five year clinical experience with the Copper 7 intrauterine device.

The clinical observation of 1547 patients who had a Copper 7 IUD inserted in a municipal hospital in New York City during the period August 1, 1974 to July 31, 1979, is presented. Despite the extreme mobility of this lower socio-economic population, complete followup was possible for 79% of the insertions. The demographic characteristics of the patients are presented, as well as the number of events and closures for the first segment of use and for all segments. The events are analyzed by patient's age, gravidity, parity and duration of use. Net annual rates for accidental pregnancies, expulsions and removals, as well as continuation rates are presented for the first 3 years of use. Net cumulative rates for the same events are presented for the 5 years of the study.

[Sterilization as a reversible method: utopia or reality? (Author's transl)]. / Reversibilite de la sterilization; utopie ou realite?

PIP: Recent technological improvements in the field of microsurgery have made reversibility of sexual sterilization possible in a great number of cases. It appears that female sterilization can be reversed in almost 60% of cases, while male sterilization can be reversed in 70% of cases. Certainly the results are good, but it would be a mistake to be too optimistic. Success rates are not the same for every surgical team, and few patients know that reverse sterilization greatly depends on the technique used for sterilization. In conclusion, sterilization should be advised and performed only when both partners are absolutely sure not to desire any more children, and must still be considered as a permanent contraceptive method.^ieng

[Tubal ligation in U.S.A. (author's transl)]. / La ligature tubaire aux Etats-Unis.

PIP: Sterilization is the most popular contraceptive method among U. S. couples who have been married for more than 10 years; there are about 12 million sterilized couples in the U. S. Voluntary sterilization is legal in most U. S. states, and the consent of one's partner is not necessary. Average age of sterilization seekers is 30. Tubal ligation is usually performed through laparotomy or, especially in more recent times, laparoscopy. Hemorrhage is the most common complication, which can be easily corrected; intestinal or peritoneal burns, or ectopic pregnancy are very rare occurrences. Reversibility depends on the sterilization technique used; improved microsurgery techniques have made it possible in many instances. Hospital stay for tubal ligation was 4.2 days in 1975; today, tubal ligation can be done on an outpatient basis, under local anesthesia only. The largest number of sterilizations in performed in the Northern and in the South-West regions of the U. S., and there seems to be a relationship between educational level of the couple, and choosing sterilization as a permanent method of contraception.^ieng

Actinomyces in the endometrium of IUD users.

The colonization of the female genital tract with Actinomyces is closely related to the presence of an IUD in the uterine cavity. This was confirmed in the present study, which shows an Actinomyces frequency of over 3% in users of IUDs, while non-users were free from the opportunistic invader. This frequency was higher with certain types of devices than with others. None of the patients with positive results had pelvic symptoms, but cases of serious infections have been reported in the literature. The length of IUD usage appears to be directly related to the incidence of this colonization. The possible pathogenesis of pelvic actinomycosis is presented; the clinical significance of asymptomatic colonization is discussed.

PIP: This study confirmed that the colonization of the female genital tract with Actinomyces is closely related to the presence of an IUD in situ. Actinomyces was identified in 24 of 763 women who had had an IUD removed, an incidence of 3.14%. No controls showed this microorganism on biopsy. The average age and parity of Actinomyces bearers were 31 and 2, respectively, with a period of IUD use ranging from 24-122 months. 13 of the patients were using Lippes loop, 6 a Copper 7, 3 a Dalkon Shield, 1 a Silverman M, and 1 a Majzlin Spring. These figures represent a positive finding in 3.36% of Lippes loop users, in 1.81% of Copper 7 users, and 10.71% of Dalkon Shield users. None of the patients with positive bacterial cultures had pelvic symptoms in this study. It was concluded that the material of which the device is made is unimportant compared with the amount of tissue injury and length of use of the device in predisposing to the development of this colonization/infection.

Mortality risk associated with female sterilization.

The mortality risk associated with female sterilization in an analysis of 255 812 procedures performed in developing countries from 1973 to 1979 is reviewed. Fifteen sterilization-related deaths were reported during this period. The overall mortality was 5.86/100 000 procedures. The most common cause of death was the result of anesthetic complications, with infection in second place. The risk of death by procedure was higher with culdoscopy than with minilaparotomy or laparoscopy. The authors believe that low mortality figures are realistic and can be achieved in developing countries when experienced surgical teams are provided with adequate facilities, observe strict medical standards, utilize minilaparotomy and laparoscopy and avoid general and spinal anesthesia.

PIP: A review was conducted of the mortality risk associated with female sterilization in an analysis of 255,812 procedures performed in developing countries over the 1973 to 1979 period. The information presented is based on a review of the clinical data and individual death reports gathered since the International Project/Association for Voluntary Sterilization (IPAVS) was organized. In this analysis, 89,006 women were sterilized by laparoscopy and 94,699 by minilaparotomy. These 2 techniques represent almost 77.5% of the total 255,812 cases. The majority of female sterilizations were performed on an interval basis. About 20% were reported as postpartum procedures. The average age of acceptors were 30-36 years and the average parity was 4-6. 15 sterilization-related deaths were reported during this period. The overall mortality was 5.86/100,000 procedures. Anesthetic complications was the most common cause of death. Infection was the 2nd most frequent cause of death. The risk of death by procedure was higher with culdoscopy than with minilaparotomy or laparoscopy.

Incidence of hyperprolactinemia during oral contraceptive therapy.

A study was undertaken to determine the incidence of increased serum levels of human prolactin (hPRL) in women during oral contraceptive therapy, and to correlate this with both the dose of oral contraceptive medication and the duration of its use. The 123 patients in this study were divided into 3 groups according to the dosage of estrogenic component of the combined oral contraceptives. Thirty percent of these women had hyperprolactinemia of varying degree. Neither the dosage of steroids within our range nor the duration of therapy correlated with the presence or degree of hyperprolactinemia. The actions of estrogen-progestin compounds on hPRL are discussed.

Serum prolactin levels in short-term and long-term use of inert plastic and copper intrauterine devices.

Serum prolactin values were assessed in 59 normally menstruating parous women; groups were divided with respect to short-term (6 weeks) and long-term (4-60 months) use of either the inert plastic IUD (Saf-T-Coil or Lippes Loop) or copper IUD (Cu-7). Preinsertion values served as controls in the short-term study while a separate control group using barrier contraception was used in the long-term study. Prospective analysis of short-term IUD use and retrospective analysis of long-term IUD use revealed no significant differences in mean hPRL compared to control values. Both short- and long-term mean values were within the normal range for serum hPRL. In addition, duration of use had no significant effect on hPRL values.