The expert witness: real issues and suggestions.

Medical malpractice lawsuits generally require expert testimony. Defendants and plaintiffs deserve expert testimony that is exacting, accurate, and consistent. A study of four frequently testifying experts was undertaken with review of depositions, reports, and trial transcripts of those experts. Contradictions in claimed medical principles from one case to the next were found and examples were cited for each expert. The review suggested that expert testimony regarding the standard of care may be neither reliable nor accurate for the purposes of judging physician conduct is lawsuits. Presently, no peer review or sanction process has been implemented to ensure accuracy and reliability of expert testimony used in medical malpractice lawsuits. We recommend changes that would include independent court-appointed experts, central filing of opinion letters by experts with authoritative text citations, and a sanction process by courts and/or authorized boards for testimony that is deemed inaccurate, false, or contradictory to the standard of care.

Anovulatory luteal cycles in primates.

The short-term therapy with gonadotropins and inhibitors of prostaglandin synthesis was administered to 12 adult cycling cynomolgus monkeys to study morphology and functions of anovulatory luteinized follicles. In Group 1, five monkeys (6 cycles) received human menopausal gonadotropin (hMG 10 I.U. FSH/10 I.U. LH per 1 kg) on cycle day (c.d.) 5 and 6. Human chorionic gonadotropin (hCG 50 I.U. per 1 kg) and hMG (5 I.U. LH and 5 I.U. FSH per 1 kg) were given at 12:00 on c.d. 7. Indomethacin (15 mg/kg) was injected at 16:30 on c.d. 7 and 08:30 on c.d. 8. Ovarian biopsy was obtained in 2 cycles. In Group 2, 7 monkeys (33 cycles) received single injection of hCG (50 I.U./kg) and hMG (5 I.U. FSH/5 I.U. LH/kg) four to one days before the expected ovulation. Two doses of Naproxen-sodium were given orally 4 and 20 hours later. After treatment, females were kept with males for 5 to 7 days. Laparotomy was performed one week after treatment. Ovarian biopsy was obtained in 5 cycles. Treatment in the midfollicular phase caused premature luteinization of the follicles and suppression of ovulation in all cycles. Histological studies revealed presence of luteinized follicles. Serum progesterone was elevated. Luteal phase averaged 13.6 days (vs. 15.8 days in ovulatory cycles). Treatment in the late follicular phase resulted in luteinization of the dominant follicle and inhibition of ovulation in 20 (61%) cycles. Luteal phase lasted 17.1 days. Serum progesterone was elevated to low or midluteal values. Gross evidence of ovulation was present in 13 (39%) cycles. One pregnancy occurred. All monkeys returned to regular, ovulatory cycles after the experiments were terminated.

Intrafascial abdominal and vaginal hysterectomy: a reappraisal.

This study was designed to provide anatomic and physiologic evaluation of the intrafascial approach to hysterectomy. Anatomy of the pericervical fascia and its relationship to the fascial and muscular layers of the vagina and the cardinal and sacrouterine ligaments were studied in human and nonhuman primates. The effect of hysterectomy on the length, configuration, and axis of the vagina was evaluated using vaginal casts. Intrafascial abdominal and vaginal hysterectomies have many advantages. Damage to the urinary tract and bowel is minimized. Separation and later closure of the pericervical fascia may allow more effective hemostasis, obliterate dead space, decrease the area of raw surfaces, and separate the vaginal cuff from the retroperitoneal space. These are the principal factors in the prevention of postoperative infection. Intrafascial hysterectomy preserves the complex anatomic relationships between the endopelvic fascia and the vagina. It provides good vaginal support and preserves or improves the length, configuration, and axis of the vagina. Intrafascial hysterectomy is indicated only for treatment of benign disease.

Vaginal morphology following hysterectomy.

This study was designed to gain more information about morphology of the vagina after hysterectomy. The prospective clinical observations of patients subjected to abdominal or vaginal extrafascial or intrafascial hysterectomy with or without correction of anatomical urinary stress incontinence were included. The length, configuration and axis of the vagina were determined using a vaginal cast technic. Vaginal casts were prepared prior to and 6 months to 4 years after surgery. The gross appearance of the vagina after hysterectomy is affected by understanding normal pelvic anatomy an physiology, careful preoperative evaluation of pelvic defects, proper planning and competent performance of surgery. Proper handling of the endopelvic fascia and its condensations, the cardinal and sacrouterine ligaments, corrects preexisting weakness, provides vaginal suspension and prevents future vaginal disfigurement. Inadequate surgical technics result in magnifying preexisting weakness of pelvic supports. Successful surgery involves correcting the levator complex by reducing and shifting the levator hiatus ventrally. Reconstruction of the perineal body is essential. This study suggests a relationship between successful surgical treatment of urinary stress incontinence and reconstruction of pelvic supportive structures, with restoration of the physiological vaginal axis.

Ureaplasma urealyticum (T-mycoplasma) in vaginal fluid and cervical mucus from fertile and infertile women.

Ureaplasma urealyticum (T-mycoplasma) was isolated more frequently and in heavier growth from cervical mucus (49%) than from vaginal fluid (34%). It was isolated in 24% of vaginal fluid samples and in 35% of cervical mucus samples from fertile women, and in 29% of vaginal fluid samples and in 47% of cervical mucus samples from infertile women. The incidence of infection was high following abortion or total hysterectomy and during pregnancy or oral contraceptive use. T-mycoplasma was also isolated from the vaginal fluid and cervical mucus of a woman with tubo-ovarian abscess, but was not present in women with Trichomonas vaginalis infection. U. urealyticum did not alter the physiophysiologic characteristics of vaginal fluid and cervical mucus or the sperm penetration and sperm viability in cervical mucus. Treatment with tetracycline eradicated the organism in 88% of the infected women. Pregnancies were recorded during a 6-month follow-up in 1 of 19 infertile women who were treated with tetracycline.

Gonadotropin binding sites in human postmenopausal ovaries.

Glucose-6-phosphate dehydrogenase (G6PD) activity and gonadotropin binding sites were localized within seven postmenopausal ovaries. G6PD was localized in the cells of cortical stroma and hilus using a histochemical technique for the reduction of the tetrazolium salt, Nitro-Blue tetrazolium. Gonadotropin binding sites were localized by autoradiography following incubation of ovarian sections with (125I-hLH) and 125I-labeled follicle-stimulating hormone (125I-hFSH) were identified in the cortical stroma and hilus cells. Since these cells contain G6PD and other enzymes necessary for steroidogenesis and also have the capacity to bind both hLH and hFSH, steroidogenesis in postmenopausal ovaries appears to be controlled by circulating gonadotropins. Blood vessels within postmenopausal ovaries also bound both gonadotropins, but 125I-hFSH binding was often more intense than 125I-hLH binding.