Incidence and Parental Perception of Cardiorespiratory Monitor Use in Preterm Infants.

The objective of this study is to examine the incidence and clinical indicators for use of cardiorespiratory (CR) monitor use. We also examined parents' perceptions on the usefulness of home CR monitoring when their preterm infants were discharged from the hospital. A retrospective patients record review was conducted to assess CR monitor use at discharge in preterm infants from January 1, 2016, to December 31, 2017. Participants received a telephone survey that examined parents' CR monitor experiences and use. Over the study period, forty-four infants were discharged home on CR monitor with the incidence rate of 8.1%. Of those, 28 parents were surveyed between 1 and 2 years post discharge. Most parents reported feeling secure but anxious using the CR monitor. Parents who reported experiencing false alarms frequently also reported having feelings of anxiety while using the CR monitor. Findings from this preliminary study support the importance of understanding the role of parent perceptions of families with infants on CR monitors.

Hyperinsulinemic hypoglycemia in growth restricted convalescent preterm neonates: clinical characteristics and impediments to early diagnosis.

OBJECTIVES: Describe clinical characteristics, course, and risk factors for hyper-insulinemic hypoglycemia (HIH) in preterm infants and identify impediments to early diagnosis. METHODS: Electronic records of infant-mother dyads were used to describe clinical characteristics, lab parameters, and course of HIH. RESULTS: All eight patients (gestational ages 26w0d-29w3d) had intrauterine growth restriction (IUGR) due to placental insufficiency, (4/8) were small for gestational age. All maintained normal glucose levels with glucose infusion during the first 48 h six of eight patients had cholestasis despite being on parenteral nutrition for short time (average 17 days). Four of eight patients were treated with diazoxide (average 22 days). Four of eight patients who recovered spontaneously (average 49 days after diagnosis) responded to continuous feeds and hydrocortisone for other clinical indications. CONCLUSIONS: In IUGR preterms, HIH is asymptomatic, may be prolonged, requiring diazoxide treatment. Transient cholestasis is seen in majority of patients. Euglycemia should be demonstrated on bolus gavage feeds, off glucocorticoids before discontinuing blood glucose monitoring.

Altered prostanoid metabolism contributes to impaired angiogenesis in persistent pulmonary hypertension in a fetal lamb model.

BACKGROUND: Persistent pulmonary hypertension of the newborn (PPHN) is associated with decreased lung angiogenesis and impaired pulmonary vasodilatation at birth. Prostanoids are important modulators of vascular tone and angiogenesis. We hypothesized that altered levels of prostacyclin (PGI2), a potent vasodilator, and thromboxane A2 (TXA2), a vasoconstrictor, contribute to impaired angiogenesis of pulmonary artery endothelial cells (PAEC) in PPHN. METHODS: PAEC were isolated from fetal lambs with PPHN induced by prenatal ductus arteriosus constriction or from sham operated controls. Expression and activity of PGI2 synthase (PGIS) and TXA2 synthase (TXAS), expression of cyclooxygenases 1 and 2 (COX-1 and COX-2), and the role of PGIS/TXAS alterations in angiogenesis were investigated in PAEC from PPHN and control lambs. RESULTS: PGIS protein and activity were decreased and PGIS protein tyrosine nitration was increased in PPHN PAEC. In contrast, TXAS protein and its stimulated activity were increased in PPHN PAEC. COX-1 and COX-2 proteins were decreased in PPHN PAEC. Addition of PGI2 improved in vitro tube formation by PPHN PAEC, whereas indomethacin decreased tube formation by control PAEC. PGIS knockdown decreased the in vitro angiogenesis in control PAEC, whereas TXAS knockdown increased the in vitro angiogenesis in PPHN PAEC. CONCLUSION: Reciprocal alterations in PGI2 and TXA2 may contribute to impaired angiogenesis in PPHN.

Single-incision total laparoscopic hysterectomy.

Single-incision laparoscopic surgery is an alternative to conventional multiport laparoscopy. Single-access laparoscopy using a transumbilical port affords maximum cosmetic benefits because the surgical incision is hidden in the umbilicus. The advantages of single-access laparoscopic surgery may include less bleeding, infection, and hernia formation and better cosmetic outcome and less pain. The disadvantages and limitations include longer surgery time, difficulty in learning the technique, and the need for specialized instruments. Ongoing refinement of the surgical technique and instrumentation is likely to expand its role in gynecologic surgery in the future. We perform single-incision total laparoscopic hysterectomy using three ports in the single transumbilical incision.

Laparoscopic myomectomy with uterine artery ligation: review article and comparative analysis.

Uterine leiomyomas are one of the most common benign smooth muscle tumors in women, with a prevalence of 20 to 40% in women over the age of 35 years. Although many women are asymptomatic, problems such as bleeding, pelvic pain, and infertility may necessitate treatment. Laparoscopic myomectomy is one of the treatment options for myomas. The major concern of myomectomy either by open method or by laparoscopy is the bleeding encountered during the procedure. Most studies have aimed at ways of reducing blood loss during myomectomy. There are various ways in which bleeding during laparoscopic myomectomy can be reduced, the most reliable of which is ligation of the uterine vessels bilaterally. In this review we propose to discuss the benefits and possible disadvantages of ligating the uterine arteries bilaterally before performing laparoscopic myomectomy.

Multiple and bilateral dermoids: a case report.

A 27-year-old nulliparous woman presented with pain in the lower abdomen for six months. She was diagnosed to have bilateral dermoid cysts. Ovarian dermoid tumors can be bilateral in up to 15% of cases. After laparoscopy, we found that she had 7 dermoid cysts on the left side and 2 dermoid cysts on the right side, which is a rare occurrence. All the dermoid cysts were enucleated laparoscopically. The cysts were placed in an endobag and retrieved by morcellation. A one year follow up showed no evidence of recurrence or granulomatous peritonitis.

Retained uterine fundus after vaginal hysterectomy.

We report a case of retained uterine fundus after vaginal hysterectomy that was subsequently removed at laparoscopy. The patient had undergone vaginal hysterectomy 8 years previously and came to our hospital with abdominal pain. Examination revealed a supravesical mass. Laparoscopy was performed and showed the uterine fundus with its cornual attachments. The mass was excised and sent for histopathologic analysis, which confirmed that it was uterine tissue. Retained uterine tissue or myoma tissue has been reported, usually after morcellation. However, to our knowledge, our case is only the second reported case of retained fundus after complete vaginal hysterectomy. Because of adhesions, it is possible that the uterus was not completely removed. In such cases, laparoscopic assistance is extremely useful.

Total laparoscopic hysterectomy for large uterus.

AIM: In this review, we assessed the feasibility of total laparoscopic hysterectomy (TLH) in cases of very large uteri weighing more than 500 grams. We have analyzed whether it is possible for an experienced laparoscopic surgeon to perform efficient total laparoscopic hysterectomy for large myomatous uteri regardless of the size, number and location of the myomas. DESIGN: Retrospective review (Canadian Task Force Classification II-1) SETTING: Dedicated high volume Gynecological laparoscopy centre. PATIENTS: 173 women with symptomatic myomas who underwent total laparoscopic hysterectomy at our center. There were no exclusion criteria based on the size number or location of myomas. INTERVENTION: TLH and modifications of performing the surgery by ligating the uterine arteries prior, myomectomy followed by hysterectomy, direct morcellation after uterine artery ligation. RESULTS: 72% of patients had previous normal vaginal delivery and 28% had previous cesarean section. Average clinical size of the uterus was 18 weeks (10, 32). The average weight of the specimen was 700 grams (500, 2240). The average duration of surgery was 107 min (40, 300) and the average blood loss was 228 ml (10, 3200). CONCLUSION: Total laparoscopic hysterectomy is a technically feasible procedure. It can be performed by experienced surgeons for large uteri regardless of the size, number or location of the myomas.

Parasitic myoma after morcellation.

We report an interesting case of parasitic fibroid which developed from a morcellation remnant following laparoscopic myomectomy. The patient presented with incidental finding of pelvic mass in 2005. She underwent laparoscopic myomectomy for a myoma extending from the Pouch of Douglas to both sides of broad ligament. She subsequently presented with abdominal pain 3 years later in 2008. She underwent total laparoscopic hysterectomy with removal of broad ligament fibroids. During her hysterectomy, a right lumbar mass attached to the omentum was detected, which was excised laparoscopically. Histopathology of the mass confirmed it to be consistent with leiomyoma. This mass could probably be a morcellation remnant that has grown to this size taking blood supply from the omentum. We report this case to emphasize that all tissue pieces that are morcellated should be diligently removed. Even small bits displaced into the upper abdomen can result in parasitic fibroids. Thus, it can be concluded that parasitic myomas can arise from morcellated remnants and grow depending on the blood supply.

Image guidance based on prostate position for prostate cancer proton therapy.

PURPOSE: To determine the target coverage for proton therapy with and without image guidance and daily prebeam reorientation. METHODS AND MATERIALS: A total of 207 prostate positions were analyzed for 9 prostate cancer patients treated using our low-risk prostate proton therapy protocol (University of Florida Proton Therapy Institute 001). The planning target volume was defined as the prostate plus a 5-mm axial and 8-mm superoinferior extension. The prostate was repositioned using 5- and 10-mm shifts (anteriorly, inferiorly, posteriorly, and superiorly) and for Points A-D using a combination of 10-mm multidimensional movements (anteriorly or inferiorly; posteriorly or superiorly; and left or right). The beams were then realigned using the new prostate position. The prescription dose was 78 Gray equivalent (GE) to 95% of the planning target volume. RESULTS: For small movements in the anterior, inferior, and posterior directions within the planning target volume (< or =5 mm), treatment realignment demonstrated small, but significant, improvements in the clinical target volume (CTV) coverage to the prescribed dose (78 GE). The anterior and posterior shifts also significantly increased the minimal CTV dose (Delta +1.59 GE). For prostate 10-mm movements in the inferior, posterior, and superior directions, the beam realignment produced larger and significant improvements for both the CTV V(78) (Delta +6.4%) and the CTV minimal dose (Delta +8.22 GE). For the compounded 10-mm multidimensional shifts, realignment significantly improved the CTV V(78) (Delta +11.8%) and CTV minimal dose (Delta +23.6 GE). After realignment, the CTV minimal dose was >76.6 GE (>98%) for all points (A-D). CONCLUSION: Proton beam realignment after target shift will enhance CTV coverage for different prostate positions.

Proton therapy coverage for prostate cancer treatment.

PURPOSE: To determine the impact of prostate motion on dose coverage in proton therapy. METHODS AND MATERIALS: A total of 120 prostate positions were analyzed on 10 treatment plans for 10 prostate patients treated using our low-risk proton therapy prostate protocol (University of Florida Proton Therapy Institute 001). Computed tomography and magnetic resonance imaging T(2)-weighted turbo spin-echo scans were registered for all cases. The planning target volume included the prostate with a 5-mm axial and 8-mm superoinferior expansion. The prostate was repositioned using 5- and 10-mm one-dimensional vectors and 10-mm multidimensional vectors (Points A-D). The beam was realigned for the 5- and 10-mm displacements. The prescription dose was 78 Gy equivalent (GE). RESULTS: The mean percentage of rectum receiving 70 Gy (V(70)) was 7.9%, the bladder V(70) was 14.0%, and the femoral head/neck V(50) was 0.1%, and the mean pelvic dose was 4.6 GE. The percentage of prostate receiving 78 Gy (V(78)) with the 5-mm movements changed by -0.2% (range, 0.006-0.5%, p > 0.7). However, the prostate V(78) after a 10-mm displacement changed significantly (p < 0.003) with different movements: 3.4% (superior), -5.6% (inferior), and -10.2% (posterior). The corresponding minimal doses were also reduced: 4.5 GE, -4.7 GE, and -11.7 GE (p < or = 0.003). For displacement points A-D, the clinical target volume V(78) coverage had a large and significant reduction of 17.4% (range, 13.5-17.4%, p < 0.001) in V(78) coverage of the clinical target volume. The minimal prostate dose was reduced 33% (25.8 GE), on average, for Points A-D. The prostate minimal dose improved from 69.3 GE to 78.2 GE (p < 0.001) with realignment for 10-mm movements. CONCLUSION: The good dose coverage and low normal doses achieved for the initial plan was maintained with movements of < or = 5 mm. Beam realignment improved coverage for 10-mm displacements.

Laparoscopic myomectomy: do size, number, and location of the myomas form limiting factors for laparoscopic myomectomy?

STUDY OBJECTIVE: To assess whether it is possible for an experienced laparoscopic surgeon to perform efficient laparoscopic myomectomy regardless of the size, number, and location of the myomas. DESIGN: Prospective observational study (Canadian Task Force classification II-1). SETTING: Tertiary endoscopy center. PATIENTS: A total of 505 healthy nonpregnant women with symptomatic myomas underwent laparoscopic myomectomy at our center. No exclusion criteria were based on the size, number, or location of myomas. INTERVENTIONS: Laparoscopic myomectomy and modifications of the technique: enucleation of the myoma by morcellation while it is still attached to the uterus with and without earlier devascularization. MEASUREMENTS AND MAIN RESULTS: In all, 912 myomas were removed in these 505 patients laparoscopically. The mean number of myomas removed was 1.85 +/- 5.706 (95% CI 1.72-1.98). In all, 184 (36.4%) patients had multiple myomectomy. The mean size of the myomas removed was 5.86 +/- 3.300 cm in largest diameter (95% CI 5.56-6.16 cm). The mean weight of the myomas removed was 227.74 +/- 325.801 g (95% CI 198.03-257.45 g) and median was 100 g. The median operating time was 60 minutes (range 30-270 minutes). The median blood loss was 90 mL (range 40-2000 mL). Three comparisons were performed on the basis of size of the myomas (<10 cm and >or=10 cm in largest diameter), number of myomas removed (or=5 myomas), and the technique (enucleation of the myomas by morcellation while the myoma is still attached to the uterus and the conventional technique). In all these comparisons, although the mean blood loss, duration of surgery, and hospital stay were greater in the groups in which larger myomas or more myomas were removed or the modified technique was performed as compared with their corresponding study group, the weight and size of removed myomas were also proportionately larger in these groups. Two patients were given the diagnosis of leiomyosarcoma in their histopathology and 1 patient developed a diaphragmatic parasitic myoma followed by a leiomyoma of the sigmoid colon. Six patients underwent laparoscopic hysterectomy 4 to 6 years after the surgery for recurrent myomas. One conversion to laparotomy occurred and 1 patient underwent open subtotal hysterectomy for dilutional coagulopathy. CONCLUSION: Laparoscopic myomectomy can be performed by experienced surgeons regardless of the size, number, or location of the myomas.

Total laparoscopic hysterectomy with earlier uterine artery ligation.

We compared the feasibility, blood loss, duration of surgery, and complications between patients in whom both uterine arteries were sutured at the beginning of total laparoscopic hysterectomy (TLH) and patients in whom suturing was done after cornual pedicles. Using a prospective study (Canadian Task Force classification II-2) at a dedicated high-volume gynecologic laparoscopy center, a total of 350 women who underwent TLH from January 2005 through January 2007 were assigned into 2 groups. The indications for TLH were predominantly myomas and menorrhagia. In group A, TLH was done by suturing both uterine arteries at the beginning of the procedure. In group B, the uterine arteries were sutured after the cornual pedicles as done conventionally. All the other pedicles were desiccated and cut either with harmonic ultracision or bipolar diathermy. The uterus with cervix was removed either vaginally or by morcellation. The median age of patients in group A was 46 years and in group B was 44 years. Mean uterine size, weight, estimated blood loss, total operating time, need for blood transfusion, and complications were analyzed. In group A the total duration of surgery was 60 minutes (range 20-210). In group B, the total duration of surgery was 70 minutes (range 30-190). In group A, the median total blood loss was 50 mL (range 10-2000). In group B the total blood loss was 60 mL (range 10-2500). The comparison between the 2 groups revealed a statistically significant difference (p <.05, Mann-Whitney test). Need for blood transfusion was less in group A. One patient in group A had secondary hemorrhage 3 weeks later and the vaginal vault was resutured. In group B, 2 patients had blood loss more than 1500 mL (uterus weight > 1000 g) and required 4 units of packed cell transfusion in each. One patient in group B with previous cesarean section had a bladder wall rent and this was sutured laparoscopically using 3-0 delayed absorbable sutures. Uterine artery ligation at the beginning of TLH as done in group A is a technically feasible procedure. It reduces the total blood loss and decreases the time taken for the procedure.

Pelvic schwannoma masquerading as broad ligament myoma.

Two cases of pelvic schwannoma appeared as broad ligament myoma. Laparoscopic myomectomy was planned for both patients in view of suspected broad ligament myoma. Intraoperative findings appeared to be degenerated myomas with suggestion of malignancy. Both patients underwent complete tumor excision laparoscopically and had uneventful postoperative recovery. Histopathologic examination confirmed them to be schwannomas. Solitary nerve sheath tumors such as benign schwannomas arising in pelvic retroperitoneum are infrequently reported and difficult to diagnose preoperatively. Complete surgical excision is the treatment of choice. Benign retroperitoneal schwannomas in 2 patients primarily given the diagnosis of myoma were treated by laparoscopic excision. A MEDLINE search did not reveal reports of removing these tumors laparoscopically.

Dose-volume comparison of proton therapy and intensity-modulated radiotherapy for prostate cancer.

PURPOSE: The contrast in dose distribution between proton radiotherapy (RT) and intensity-modulated RT (IMRT) is unclear, particularly in regard to critical structures such as the rectum and bladder. METHODS AND MATERIALS: Between August and November 2006, the first 10 consecutive patients treated in our Phase II low-risk prostate proton protocol (University of Florida Proton Therapy Institute protocol 0001) were reviewed. The double-scatter proton beam plans used in treatment were analyzed for various dosimetric endpoints. For all plans, each beam dose distribution, angle, smearing, and aperture margin were optimized. IMRT plans were created for all patients and simultaneously analyzed. The IMRT plans were optimized through multiple volume objectives, beam weighting, and individual leaf movement. The patients were treated to 78 Gray-equivalents (GE) in 2-GE fractions with a biologically equivalent dose of 1.1. RESULTS: All rectal and rectal wall volumes treated to 10-80 GE (percentage of volume receiving 10-80 GE [V(10)-V(80)]) were significantly lower with proton therapy (p < 0.05). The rectal V(50) was reduced from 31.3% +/- 4.1% with IMRT to 14.6% +/- 3.0% with proton therapy for a relative improvement of 53.4% and an absolute benefit of 16.7% (p < 0.001). The mean rectal dose decreased 59% with proton therapy (p < 0.001). For the bladder and bladder wall, proton therapy produced significantly smaller volumes treated to doses of 10-35 GE (p < 0.05) with a nonsignificant advantage demonstrated for the volume receiving < or =60 GE. The bladder V(30) was reduced with proton therapy for a relative improvement of 35.3% and an absolute benefit of 15.1% (p = 0.02). The mean bladder dose decreased 35% with proton therapy (p = 0.002). CONCLUSION: Compared with IMRT, proton therapy reduced the dose to the dose-limiting normal structures while maintaining excellent planning target volume coverage.

Rectal dose-volume differences using proton radiotherapy and a rectal balloon or water alone for the treatment of prostate cancer.

PURPOSE: To describe dose-volume values with the use of water alone vs. a rectal balloon (RB) for the treatment of prostate cancer with proton therapy. MATERIALS AND METHODS: We analyzed 30 proton plans for 15 patients who underwent CT and MRI scans with an RB or water alone. Simulation was performed with a modified MRI endorectal coil and an RB with 100 mL of water or water alone. Doses of 78-82 gray equivalents were prescribed to the planning target volume. The two groups were compared for three structures: rectum, rectal wall (RW), and rectal wall 7 cm (RW7) at the level of the planning target volume. RESULTS: Rectum and RW volumes radiated to low, intermediate, and high doses were small: rectum V10, 33.7%; V50, 17.3%; and V70, 10.2%; RW V10, 32.4%; V50, 20.4%; and V70, 14.6%. The RB effectively increased the rectal volume for all cases (139.8 +/- 44.9 mL vs. 217.7 +/- 32.2 mL (p < 0.001). The RB also decreased the volume of the rectum radiated to doses V10-V65 (p < or = 0.05); RW for V10-V50; and RW7 for V10-V35. An absolute rectum V50 improvement >5% was seen for the RB in 5 of 15 cases, for a benefit of 9.2% +/- 2.3% compared with 2.4% +/- 1.3% for the remaining 10 cases (p < 0.001). Similar benefit was seen for the rectal wall. No benefit was seen for doses > or =70 gray equivalents for the rectum, RW, or RW7. No benefit of < or =1% was seen with an RB in 46% for the rectum V70 and in 40% for the rectal wall V70. CONCLUSIONS: Rectum and rectal wall doses with proton radiation were low whether using water or an RB. Selected patients will have a small but significant advantage with an RB; however, water alone was well tolerated and will be an alternative for most patients.

Multiple leiomyomas after laparoscopic hysterectomy: report of two cases.

We report on 2 cases of multiple leiomyomas arising in the pelvis after laparoscopic hysterectomy. One patient underwent laparoscopic myomectomy at 41 years of age and subsequently had a total laparoscopic hysterectomy for myomas 4 years later. Three years post-hysterectomy, she presented with pelvic masses that were removed laparoscopically and were leiomyomas on histopathologic examination. The other patient underwent supracervical hysterectomy for myomas with removal of a parasitic myoma from underneath the dome of the diaphragm. Eight months post-hysterectomy, she came to our office with a pelvic mass with a large myoma that was removed laparoscopically. Disseminated leiomyomas may occur after hysterectomy; and though various theories have been proposed to explain this remarkable entity, none has found universal acceptance. A thorough MEDLINE search did not reveal any reports of large pelvic masses of this size after hysterectomy or their management laparoscopically, and these are probably the first reported cases.

Laparoscopic metroplasty for bicornuate uterus.

This is a case study of a 29-year-old nulliparous woman with a bicornuate uterus who had a poor obstetric history in whom we performed a laparoscopic metroplasty. She was advised to use barrier contraception for 3 months. A repeat hystero-laparoscopy performed 3 months later revealed a single large uniform uterine cavity without any adhesions. The patient had an incompetent cervical os after surgery and was advised to undergo cervical cerclage on conception.