Appendectomy during pregnancy: a survey of two army medical activities.

Acute appendicitis is the most common nonobstetrical surgical condition of the abdomen complicating pregnancy. Appendectomy reportedly is performed during pregnancy once for every 1,500 deliveries. Although the incidence of appendicitis occurring in pregnant women is considered to be the same as in nonpregnant women, the signs and symptoms, and the laboratory findings usually associated with appendicitis in the nonpregnant condition, are frequently unreliable during pregnancy. Using the Computer Diagnostic Data System, we completed a retrospective analysis on all appendectomies performed at two Army Medical Activities (MEDDACs) during a 2-year period. With a representative large Army MEDDAC and a representative medium-sized Army MEDDAC studied, the incidence of appendectomy during pregnancy was the same frequency as in previous reports. The only consistent finding in all pregnant patients who underwent appendectomy was right lower quadrant abdominal pain. Presenting signs and symptoms, clinical evaluations, laboratory findings, and surgical management is discussed. No morbidity or mortality occurred during this study.

Uterine packing in the combined management of obstetrical hemorrhage.

Uterine packing to control obstetrical hemorrhage has been generally discouraged over the past several decades. Intractable uterine hemorrhage postpartum or following an abortion is an extremely vexing management problem for the physician and continues to be a leading cause of maternal mortality. Uterine packing should be considered as a presurgical management tool after lacerations of the lower genital tract, uterine rupture, or retained products have been ruled out and when conventional therapy fails to control uterine hemorrhage. We describe two obstetrical patients with intractable uterine hemorrhage who were managed with uterine packing in combination with other methods of therapy. Causes of obstetrical hemorrhage and techniques of packing the uterus are discussed.

Fine needle aspiration of palpable breast masses with immediate cytologic interpretation in an OB/GYN residency training program: a preliminary report.

Increasing emphasis has been placed on the training of obstetrics and gynecology residents in the evaluation of patients with breast disease. In the past, one had to refer to the surgery, radiology, or pathology literature to obtain current information on fine needle aspiration. With the present mandate to include breast disease in the academic curricula of obstetrics and gynecology residency training, the Department of Obstetrics and Gynecology, Tripler Army Medical Center, initiated training in breast evaluation. This preliminary report describes the Tripler Obstetrics and Gynecology Department Breast Evaluation Clinic and presents the findings of the first 40 patients.

Laparoscopically assisted vaginal hysterectomy in an Army medical center.

Over the past 5 years, laparoscopic assisted vaginal hysterectomy (LAVH) has progressed from an experimental procedure to an alternative operation when abdominal hysterectomy is indicated. During a 15-month period, 31 patients underwent LAVH at Tripler Army Medical Center for treatment of gynecologic conditions that traditionally required abdominal hysterectomy. The benefits of the procedure and the complications encountered during surgery are discussed. A comparison of our data with data presented in other reports in the literature is considered favorable. While the complication rate was 16%, there was no mortality or serious morbidity. With experience and proper training of gynecologic surgeons, LAVH is an alternative to abdominal hysterectomy in selected cases.

Echovirus 30 infection and aseptic meningitis in parents of children attending a child care center.

In July 1992, 13 parents with children attending a child care center (CCC) developed aseptic meningitis (AM) due to echovirus 30 (E30). To determine the extent of illness and risk factors for transmission, survey and blood specimens were collected from CCC families and teachers and from adult and pediatric controls. Infection was defined as the presence of anti-E30 IgM antibodies. CCC parents (60%, 67/111) and children (75%, 79/105) had significantly higher infection rates than did teachers (14%, 3/22), adult controls (24%, 10/41), and pediatric controls (24%, 17/70). Infected CCC parents had more severe illness (18% [12/65] had AM; 11% [7/65] were hospitalized) than did infected CCC children (3% [2/79] had AM and 1% [1/79] were hospitalized). More frequent handwashing among teachers compared with parents and among mothers of toddlers was associated with significantly lower rates of infection (P < or = .05). Education of parents about good handwashing practices may reduce transmission of E30 and other infectious agents from children to adults.

Effects of insulin on fatty acid reesterification in healthy subjects.

The effects of insulin on triacylglycerol/fatty acid cycling (fatty acid reesterification) were studied in 12 normal subjects during euglycemic hyperinsulinemia with the use of stable isotope dilution analysis ([2H5]glycerol and [1-13C]palmitate) in combination with indirect calorimetry. During basal conditions, 5.6 +/- 0.6 mumol.kg-1 x min-1 of fatty acid were released of which approximately 3.3 mumol.kg-1 x min-1 were oxidized and approximately 2.2 mumol.kg-1 x min-1 were reesterified. A minority of the recycled fatty acid, (0.8 +/- 0.4 mumol.kg-1 x min-1) never left the intracellular space before being reesterified (intracellular triacylglycerol/fatty acid cycling), whereas the majority (1.2 +/- 0.4 mumol.kg-1 x min-1) were first released into the extracellular space and then reesterified in various organs (extracellular triacylglycerol/fatty acid cycling). In response to insulin, fatty acid release declined by 71% (from 5.6 +/- 0.6 to 1.6 +/- 0.2 mumol.kg-1 x min-1). Fatty acid oxidation (measured by indirect calorimetry) declined by 55% (from 3.3 +/- 0.3 to 1.5 +/- 0.3 mumol.kg-1 x min-1) and total triacylglycerol/fatty acid cycling was completely suppressed (from 2.2 to 0.0 mumol.kg-1 x min-1). Fatty acid release, oxidation, total and extracellular triacylglycerol/fatty acid cycling all correlated positively with plasma fatty acid concentrations. These data showed that insulin profoundly suppressed fatty acid release, oxidation as well as reesterification of those fatty acids that had entered the extracellular compartment. They suggested that physiological concentrations of insulin suppressed extracellular fatty acid reesterification primarily by inhibiting lipolysis.

Ethanol inhibits insulin action on lipolysis and on insulin release in elderly men.

We have studied effects of ethanol on insulin's ability to suppress its own release and on its antilipolytic action in 12 healthy elderly men during euglycemic hyperinsulinemia. Insulin secretion was estimated from plasma C-peptide concentrations. Lipolysis was determined with the two stable isotopes [2H5]glycerol and [1-13C]palmitate. Hyperinsulinemia (approximately 350 pM) decreased plasma C-peptide by approximately 60% (from 325 to 122 pM, P < 0.05). Ethanol (approximately 10 mM) completely prevented the fall in C-peptide concentration. Ethanol decreased the antilipolytic action of insulin by approximately 40% [with insulin alone, glycerol rate of appearance (Ra) decreased from 1.8 to 0.6 mumol.kg-1 x min-1; with insulin + ethanol, it only decreased from 1.8 to 1.1 mumol.kg-1 x min-1]. Ethanol did not affect palmitate Ra, which fell from 1.4 to 0.6 mumol.kg-1 x min-1 with insulin and from 1.4 to 0.3 mumol.kg-1 x min-1 with insulin plus ethanol. Fatty acid reesterification was not affected by insulin but tripled (from 0.6 to 1.9 mumol.kg-1 x min-1) in response to insulin plus ethanol. Our data showed that modest concentrations of ethanol suppressed the inhibitory actions of insulin on its own release and on lipolysis. The inhibition by ethanol of various insulin actions, including glucose disposal, lipolysis, and insulin release, in diverse tissues such as muscle, adipose tissue, and pancreas raises the possibility that ethanol may produce a state of generalized insulin resistance.

Effects of age and body fat on insulin resistance in healthy men.

OBJECTIVE: Aging is known to be associated with increasing insulin resistance and declining glucose tolerance. The cause for the insulin resistance, however, remains uncertain. In this study, we examined the hypothesis that at least part of the insulin resistance may be attributable to age-related changes in body composition and muscle blood flow rather than age itself. RESEARCH DESIGN AND METHODS: We studied 6 healthy, elderly (66.2 +/- 1.7 yr) and 6 younger, healthy men (31.8 +/- 3.0 yr) matched for height and weight by determination of their body composition (by underwater weighing), leg blood flow (by mercury strain-gauge plethysmography), rates of glucose uptake (by stable isotope dilution analysis with 6.6 D2-glucose), and carbohydrate oxidation (by indirect calorimetry) during euglycemic hyperinsulinemic clamping. RESULTS: Body fat (kg fat mass or in percentage of body weight), rates of insulin-stimulated leg blood flow, glucose uptake, oxidation, and storage were all similar in elderly and younger men. Body fat (in percentage of body weight) of both elderly and younger men correlated closely and negatively with glucose uptake (r = -0.73, P < 0.01), glucose oxidation (r = -0.67, P < 0.05), and with glucose storage (r = -0.65, P < 0.05). In contrast, age did not correlate significantly with any parameter of glucose metabolism. CONCLUSIONS: Our data suggested that insulin sensitivity in men until around 60-70 yr of age appears to be determined more by body fat than by age.