Loop diathermy excision compared with cervical laser vaporisation for the treatment of intraepithelial neoplasia: a randomised controlled trial.

OBJECTIVE: To determine whether loop diathermy excision of the transformation zone and laser vaporisation are equally effective in the treatment of cervical intraepithelial neoplasia. DESIGN: Randomised controlled trial. POPULATION: Women referred for evaluation of cytological abnormality who were considered suitable for outpatient local destructive treatment. SETTING: Seven colposcopy units in the North West Region. METHODS: Loop diathermy excision of the transformation zone and laser vaporisation. MAIN OUTCOME MEASURE: Smear reported as moderate dyskariosis or worse following treatment. RESULTS: Of 289 women randomised, 285 had one or more smears following treatment. Women were more likely to have a smear reported as moderate dyskariosis or worse following laser vaporisation [hazard ratio 3.01 (95% CI 1.27 to 7.12)]. The cumulative risk of a smear reported as moderate dyskariosis or worse was 6.0% at six months and 12.1% at three years in those allocated laser vaporisation, and 2.0% at six months, and 3.3% at three years in those allocated loop diathermy excision of the transformation zone. CONCLUSIONS: Loop diathermy excision is a more effective treatment of cervical intraepithelial neoplasia than laser vaporisation.

Failed instrumental delivery: how safe is the use of a second instrument?

An audit of failed instrumental deliveries was undertaken to assess the incidence of complications and the adequacy of documentation. When one instrument has failed to effect delivery, the use of a second instrument could in most cases be used to complete the delivery without harm to the mother or baby. However in a small but significant number of cases there are severe maternal or perinatal complications, and these could be the subject of litigation. This could be avoided by adequate pre-application assessment, standard conduct of instrumental delivery and full documentation. Inadequate documentation could be overcome by the use of a pro forma. Selective use of plastic and metal cups could reduce the incidence of failed attempts.

Diagnostic lessons of mucosal melanoma with osteocartilaginous differentiation.

AIMS: To document the clinical, morphological and immunohistochemical features of two cases of primary mucosal melanoma with osteocartilaginous differentiation. MATERIALS AND METHODS: Two cases of mucosal melanoma with cartilage and bone formation are reported, one arising in the vagina of a 79-year-old woman and one in the oral cavity of a 67-year-old man. The vaginal melanoma exhibited only cartilaginous differentiation. The oral cavity mucosal melanoma exhibited both bone and cartilage formation and was remarkable for its multifocality, long history not associated with metastases and its lengthy manifestation of dual morphologies: some of the tumours were typical in situ/invasive melanotic melanomas whilst the others were composed of amelanotic spindle and epithelioid cells with osteocartilaginous tissue. One of the lesions exhibited in situ and invasive melanoma with transition to an osteogenic tumour in places. The patient also developed nonosteogenic malignant melanomas in the nasal cavity and nasopharynx. CONCLUSIONS: Malignant melanomas showing foci of osteocartilaginous differentiation are extremely rare with only 18 cases reported. Primary mucosal malignant melanomas of vagina and oral cavity showing osteocartilaginous differentiation have not previously been documented. Primary vaginal melanoma with cartilaginous differentiation must be distinguished from primary malignant mixed Müllerian tumour whilst malignant change in a pleomorphic adenoma, sarcomatoid carcinoma, osteogenic sarcoma and mesenchymal chondrosarcoma are included in the differential diagnosis of primary oral mucosal melanomas with osteocartilaginous differentiation. In this context, immunohistochemistry using antibodies to cytokeratin, S100 protein and MIC2 is of value.

Post-operative spindle cell nodule of the vulva.

A case of post-operative spindle cell nodule arising in the vulva of a 33-year old woman is reported and the relevant literature reviewed. This is an uncommon, benign lesion which develops soon after a surgical procedure and which is composed of mitotically active spindle cells, causing possible confusion with sarcoma. Knowledge of the clinical history and an awareness of the existence of such lesions is necessary in order to avoid misinterpretation.

Recreational sports and the weekend athlete.

It is important to design an exercise program that provides an adequate amount of activity to attain maximal benefits at the lowest risk to the participant. Permanent lifestyle changes in eating and activity habits should be included in the primary goals of all programs.

Whiplash syndrome. Fact or fiction?

A sprain/strain syndrome or "whiplash injury" is the most common cervical injury associated with rear-end impact motor vehicle accidents. This results in a complex injury, often associated with extensive soft tissue injury in the cervical spine. There is additional potential for long term alteration in neurologic, muscular, and skeletal function. Evaluation and treatment should follow standard orthopedic principles.

The computer. An orthopedic instrument.

The computer has become an important tool in orthopedic practice. Indeed, it is now invaluable and will soon be essential. It is still possible to run an orthopedic office without a computer--just as it is still possible to perform meniscectomy by arthrotomy--but that is not what most of us would do. The computer enhances efficiency, can improve business practice, assists in marketing, and helps store and retrieve medical information. The ultimate impact is not only on "business" functions but also on the quality of care.