Current status of vaginal sonography. Part I: Basic principles and gynecologic diagnosis

During the last 8 years transvaginal sonography or vaginosonography has become an essential part of diagnosis in gynaecology and obstetrics. Due to the outstanding image quality of the pelvic viscera without requiring a full bladder technique, vaginosonography is performed more and more often in clinical and private medical practice. In several applications transvaginal scanning has replaced transabdominal scanning. Due to the development of small-diameter probes it is now possible to examine patients with an intact hymen or with a very narrow vagina. The combination of transvaginal probe and Doppler-/colour Doppler technique opens up new avenues in gynaecological ultrasound, especially for tumour diagnosis in the lower pelvis. However, transvaginal sonography cannot be used universally in gynaecology and obstetrics as the diagnosis is limited to findings in the lower pelvis because of the limited penetration depth.     

Ergot alkaloids. Current status and review of clinical pharmacology and therapeutic use compared with other oxytocics in obstetrics and gynaecology

Ergot alkaloids are well known preparations. Ergot alkaloids used in obstetrics and gynaecology are ergometrine (ergonovine; EM), methylergometrine (methergine; ME) and bromocriptine. The pharmaceutical properties of ME EM) are critical. To guarantee stability, ME and EM ampoules should be stored in a cool, dark place. ME and EM tablets are unstable in all conditions and they show an unpredictable bioavailability, which prevents oral use of the drugs for any purpose. ME and EM are known for their strong uterotonic effect and, compared with other ergot alkaloids, for their relatively slight vasoconstrictive abilities. ME and EM do have a place in the management of the third stage of labour as they are strong uterotonics. They act differently from oxytocin and prostaglandins, and have different adverse effects. Oxytocin should be used as prophylaxis or a the drug of first choice; next, ME or EM should be used, and if none of these drugs produce the desired effects, prostaglandins should be used to control bleeding. Ergot alkaloid use in gynaecology has been limited and today is discouraged even in essential menorrhagia. It is suggested that EM and ME be used (parenterally) only in first trimester abortion curettage, to reduce blood loss. Bromocriptine has been used for lactation suppression. However, alternatives such as cabergoline, which possess fewer adverse effects, are now available and therefore preferred for this indication. In sum, there is no place for the prophylactic use of ME and EM in obstetrics or gynaecology. They can be used for therapeutic purposes in the third stage of labour. During use, the practitioner must be alert for adverse effects.     

Our gynecologic heritage. Robert von Olshausen (1835-1915), pioneer in surgical gynecology. 5th contribution on the history of the Berlin Society of Obstetrics and Gynecology

Robert von Olshausen was an outstanding German gynecologist at the turn of the century and a pioneer of operative gynaecology. His fields of excellency were ovarotomy, the problems of asepsis, carcinoma therapy and the development of obstetrics in general. Under his chairmansship, the Berlin Department of Obstetrics and Gynecology (Universit?ts-Frauenklinik) became the leading Clinic in Germany. For many years Olshausen was the chairman of the Berlin Society of Obstetrics and Gynecology, since 1894 as honorary chairman. The present paper is a biography of Robert von Olshausen, showing his importance for the development of the modern gynaecology in Berlin and Germany.     

Decreased hypotensive responsiveness to nitric oxide donor S-nitroso N-acetyl-DL-penicillamine (SNAP) in spontaneously hypertensive (SHR) rats

The nosocomial infection (NI) rate in German hospitals was studied in order to create reference data for comparison in hospitals where ongoing surveillance is impossible. The study was designed as a one-day prevalence study. Patients in 72 selected hospitals (inclusion criteria: acute care hospitals with departments for general medicine, surgery, obstetrics/gynaecology) were examined by four external investigators (physicians trained and validated in the diagnosis of NI). A total of 14,996 patients were studied. The overall prevalence rate was 3.5% (CI 3.1-3.9) with a variation of 0-8.9% between hospitals. The commonest NI were: urinary tract infection (42.1%), lower respiratory tract infection (20.6%), surgical site infections (15.8%) and primary sepsis (8.3%). The highest prevalence rate (15.3%) was found in intensive care ward patients, followed by surgery (3.8%), general medicine (3.0%) and gynaecology/obstetrics (1.4%). The infection rate varied significantly with hospital size. A microbiology laboratory report was only available for 56.5% of patients thought to have an NI, and there were remarkable differences between hospitals with and without an on-site microbiology laboratory. Because of this and other methodological reasons the NI prevalence rates reported here may represent the absolute minimum of nosocomially infected patients in Germany.     

Practising obstetrics and gynaecology in areas with a high prevalence of HIV infection

What is it like to practise obstetrics and gynaecology in a country with a high prevalence of HIV infection? My experience relates especially to Zimbabwe, but the same factors apply equally well to Zambia, Zaire, Uganda, Kenya, Tanzania, Malawi, and Mozambique. Within a population of 11 million in Zimbabwe, at least 1 million are HIV positive according to the official figures. AIDS often means "home-based care"; the nearest clinic or hospital, which has very little to offer, may be 3 hours away by wheelbarrow. Many patients who die with chronic diarrhoea lack a piped water supply nearby, an indoor toilet, or even a waterproof sheet. Every year in Zimbabwe there are 120,000 confinements of HIV-positive women compared with 7000 HIV-positive pregnancies in the USA. Transmission of the virus in Africa is mainly heterosexual and vertical, although blood transfusion still plays a part. Intravenous drug use is not a problem but alcohol is, by way of promoting risky behaviour. A secondary epidemic of tuberculosis (TB) (also among HIV-negative persons) adds to the difficulties in sub-Saharan Africa.     

Neuroradiologic evaluation of patients with acute stroke treated with recombinant tissue plasminogen activator. The rt-PA Acute Stroke Study Group

The breast is an organ of reproduction. The diagnosis and treatment of most benign breast conditions and a knowledge of the contemporary treatment of breast cancer are essential components of the current practice of obstetrics and gynecology.     

Clinical genetics in The Netherlands. I. Organization, activities and laboratory diagnosis]

The main feature of clinical genetics is the involvement of close relatives in the diagnostics of a hereditary disorder, and the possible consequences of the findings for future generations. Complex genetic counseling is required in cases with different, possibly hereditary disorders or congenital anomalies in the family or by a syndrome with variable risks of recurrence, depending on the exact nature of the disorder; also the difficult, often emotionally charged choices with which counselees are faced demands the expertise of a clinical genetic centre. Results of follow-up studies after genetic counseling show that experience with a handicap or disease in the own environment and the presence of healthy issue are the main determinants for the decision about reproduction of persons with an enhanced genetic risk who request counseling. Because of the great variety in perception of risks and of the severity of a disorder, and because of the marked clinical heterogeneity, rigid legislation should be avoided in the field of prenatal diagnosis. In the future, the training of the clinical geneticist has to be adapted to the rapid progress in human genetics. Increasingly, the clinical geneticist will function in collaboration with other disciplines such as oncology, obstetrics and gynaecology, paediatrics and neurology; in connection with family testing and counseling, there will also be more collaboration with primary health care.     

A blueprint for academic obstetrics and gynecology

A consensus conference sponsored by the Council of University Chairs of Obstetrics and Gynecology in February 1997 formulated the organization's response to the many external issues affecting academic medicine and obstetrics and gynecology including 1) a new practice model based on "wellness," 2) reimbursement changes that have jeopardized traditional revenue sources, 3) an emphasis on quality assurance based on outcomes research and evidence-based medicine, 4) the concept of lifelong learning dictated by an expanding knowledge base and new technology, 5) insufficient resources for basic and clinical investigation in obstetrics and gynecology, 6) workforce statistics indicating stabilization in the number of subspecialists, 7) the increasing diversity of the United States population. Recommendations were developed that are intended to foster change and contribute to the design of academic programs. These include appropriate training for residents as providers of primary care, with an emphasis on continuity clinics, an interdisciplinary curriculum in women's health for medical students; promotion of gender, racial, and ethnic diversity at all levels of medical education and academic leadership; creation of clinical trials research units; and the development of expanded opportunities for research in obstetrics and gynecology supported by the National Institutes of Health.     

An obstetrics and gynaecology graduate residency programme in Venezuela

We present our experience on the design and development of a gynaecology and obstetrics graduate residency programme, developed in the Department of Obstetrics and Gynecology at the Dr Adolfo Prince Lara Hospital, Puerto Cabello, Venezuela, in which medical specialists and residents participate synergistically. From January to September 1993, curricular activities were planned and students selected. The programme started in October 1993, with six residents for a three-year programme. Courses were given by medical specialists from the Department. In addition to a Programme Coordinator, there is also a Residents' Coordinator, appointed for a two-month term of office; specific functions were assigned for residents occupying this position. All the programmed activities for three years were accomplished, including lectures and rotations, with an important record of surgical interventions. In our grade system, residents got an average of 18 over a maximum of 20 points. Residents also participated as speakers in workshops, special courses and national medicinal meetings, in which they presented a total of nine papers. Activities were evaluated bimonthly in meetings with students and each semester by the Graduate Committee. The first class graduated in September 1996. Results suggest that resident participation in graduate programmes is an important part of their education.     

Effect of training on endoscopic intracorporeal knot tying

Training in endoscopic, intracorporeal knot tying, was evaluated in 29 obstetrics and gynaecology trainees who performed 100 consecutive intracorporeal, two turn, flat, square knots. An obvious learning curve was observed. With training the quality of the knots increased, whereas the mean duration to tie a knot decreased from 277 +/- 114 to 67 +/- 27 s for the first 10 and the last 10 knots respectively. The initial and final duration of knot tying were lower in more experienced trainees, as estimated by the year of training or the Royal College of Obstetrics and Gynaecology (RCOG) level of experience. More specifically, duration of knot tying was shorter when more diagnostic laparoscopies, laparoscopic sterilizations or adnexectomies had been performed. This effect of previous experience was however limited compared with the overall effect of training. Previous passive experience, however, as determined by the number of assisted or observed surgical interventions, did not affect the learning curves. Speed of knot tying was slightly higher in trainees who spent more of their leisure time performing handicrafts than in trainees who were more interested in reading, but although significant, these differences were only marginal. In conclusion, the data show an important effect of training on the speed and quality of intracorporeal knot tying and confirm that learning curves improve with previous training.     

Pathogenic potential of Gardnerella vaginalis on the female urogenital system

The prevalence of certain characteristics of genital discharge like (a) watery variety in sexually transmitted disease (STD) clinic 34% and in gynaecology clinic 26.6%, (b) fishy odour in STD clinic 29.2% and in gynaecology clinic 12.2% and (c) pH > 4.5 in STD clinic 53.6% and in gynaecology clinic 43% was notable. On the other hand, occurrence of "clue cells" (in STD clinic 41.4% and in gynaecology clinic 39.5%) did not show difference in the aforesaid clinics. The preponderance of watery discharge in the STD clinic appears to be related to G vaginalis (in STD clinic 26.8% and in gynaecology clinic 9.3%). It is intriguing to note that G vaginalis was isolated from leucorrhoea (in STD clinic 19.5% and in gynaecology clinic 9.3%) and inapparent (in 10%) cases and normal (in 4.2%) cases. Single infection with G vaginalis in one particular case had profuse watery discharge, pH > 4.5 and there was occurrence of "clue cells". Likewise, in multiple infections revealing G vaginalis (29 cases) as one of the potential agents, 78.5% had profuse, 53.8% watery discharge of which 53.5% had "clue cells" and 81% had pH > 4.5. In mixed type of infections, the U urealyticum (53.8%) and M hominis (30.6%) were conspicuous in bacterial vaginosis. Cervicitis, erosion cervix or urethral syndrome were unrelated to G vaginalis. All cases of G vaginalis infection responded to metronidazole with remission of leucorrhoea in 25.9% cases.     

Organization of obstetric ultrasonography in Denmark 1995--description of the development since 1990

With the aim to provide an overview of the current organisational status of obstetric ultrasound in Denmark and to describe the development since 1990, a questionnaire was sent in spring 1995 to all 49 departments responsible for the hospital antenatal care program. In addition a questionnaire was sent to the 14 imaging diagnostic departments providing ultrasound services for those of the 49 departments that had either insufficient or no ultrasound facilities. The response rate was 100. Since 1986 the National Board of Health in Denmark has recommended not to screen. At the time of the study the issue was under consideration as part of a general revision of the antenatal care program. Obstetric ultrasound was performed in 30 obstetric, 11 surgical, 12 radiological, 1 image diagnostic and 1 ultrasound department. In total approx. 140,000 obstetric ultrasound examinations were performed in 1994 in contrast to approx. 120,000 in 1989. Fifty-one point four percent of the pregnant population was routinely offered an ultrasound scan in the 10-20th week of gestation (1990: 39.9%). For 19.5% the offer included screening for foetal malformations (1990: 16.5%). In total 34 departments, responsible for the antenatal care of 86.3% of the pregnant population, wanted to continue or start giving an offer of ultrasound screening. The study documents a significant technology diffusion process of ultrasound into the specialty of obstetrics and gynaecology.     

Modeling, imitation, and observational learning in remediation experimentation 1979–1988: An analysis of the validity of research designs and outcomes.

Modeling procedures are frequently used as remedial and instructional techniques with diagnostic groups such as autistic, mentally retarded, and learning-disabled children. The authors describe the theoretical underpinning of the use of modeling in these atypical groups and then consider the scientific merit of 65 studies in 10 diagnostic categories, analyzed from a research design-validity basis. In the analysis of experimental design requirements for remediation research, it was suggested that within-S procedures are essential for interpretable experiments with atypical groups, but no appropriate within-S designs were found in the corpus of studies analyzed. Of the relatively few between-S experiments in the corpus, most were found to be valid in terms of their including the manipulation of at least one modeling variable. (French abstract) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The invention of the modern uroflowmeter by Willard M. Drake, Jr at Jefferson Medical College

OBJECTIVES: As a means of enhancing public health efforts to control sexual transmission of human immunodeficiency virus (HIV), methods were developed to report on risk behavior in a manner that is comparable and widely interpretable. METHODS: An elementary sexual behavior risk index (the vaginal episode equivalent index) that is in accord with some of the essential knowledge about sexual transmission of HIV is described, and a multivariate ordinal risk (MOR) method that can be used to improve such risk indices is introduced. RESULTS: An example shows that these approaches are applicable to observational studies of seroconversion. CONCLUSIONS: The MOR represents a powerful new tool to develop valid comparable measures of sexual risk behavior and, thereby, to advance HIV prevention research.     

Illusory correlation as an obstacle to the use of valid psychodiagnostic signs.

Practicing psychodiagnosticians (N = 32), when surveyed, failed to report observing Wheeler-Rorschach Signs 7 and 8 as accompanying male homosexuality although research evidence indicates that these are valid. They instead reported observing Wheeler Signs 4, 5, 16, 19, and 20, which research literature indicates are invalid. These signs were found to have much stronger rated, verbal associative connections to male homosexuality than the unpopular valid signs. 693 undergraduates (divided among 13 conditions) viewed 30 Rorschach cards on each of which was arbitrarily designated a patient's response and his 2 symptoms. The Ss "rediscovered" the same invalid Rorschach content signs of homosexuality as the clinicians reported, although these relationships were absent in the experimental materials. They did so regardless of the degree to which the clinically valid signs were valid in the contrived task materials. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Phosphorylation of ATPase subunits of the 26S proteasome

OBJECTIVE: To evaluate the impact of the 1993 French National Policy which made it mandatory to offer screening for the presence of human immunodeficiency virus (HIV) to all pregnant women who planned to give birth, although women remained free to refuse the test. DESIGN: Successive surveys in April 1992 and May 1994 in south-eastern France. Logistic regressions were performed to identify factors which affected access to HIV testing for women who gave birth and those who terminated their pregnancy, and for each year of study. MAIN OUTCOME MEASURES: Attitudes and access to HIV testing among pregnant women, irrespective of pregnancy outcome. SETTING: All obstetrics and gynaecology departments and abortion clinics in the region. POPULATION: 3497 women in 1992 (2775 who were delivered and 722 who chose termination) and 3407 in 1994 (2701 who were delivered and 766 who chose termination). The response rates were 82% and 88%, respectively. RESULTS: In 1994 of women who were delivered, 73% had an HIV test, compared with 63% in 1992 (P < 0.001); however of women who terminated their pregnancy, only 28% had an HIV test, compared with 24.5% in 1992 (P not significant), although they were more at risk for HIV infection. Socioeconomic differences affecting access to testing were reduced between 1992 and 1994, but only among women who gave birth. CONCLUSION: Introduction of a policy which makes it mandatory to offer HIV screening to all women who intended to have their baby improved access to screening but did not improve the rate of preventative counselling. A mandatory requirement to offer HIV screening should be extended to women who request termination of pregnancy.     

Statistical principles for clinical trials

If a trial is to be well designed, and the conclusions drawn from it valid, a thorough understanding of the benefits and pitfalls of basic statistical principles is required. When setting up a trial, appropriate sample-size calculation is vital. If initial calculations are inaccurate, trial results will be unreliable. The principle of intent-to-treat in comparative trials is examined. Randomization as a method of selecting patients to treatment is essential to ensure that the treatment groups are equalized in terms of avoiding biased allocation in the mix of patients within groups. Once trial results are available the correct calculation and interpretation of the P-value is important. Its limitations are examined, and the use of the confidence interval to help draw valid conclusions regarding the clinical value of treatments is explored.     

Centrifuge Modeling of Moisture Migration in Silty Soils

An effort has been made to demonstrate use of a small geotechnical centrifuge as a research tool to understand moisture migration in a silty soil. Such a basic study is essential for understanding the much more complex phenomenon of solute transport through a soil, where the physical, chemical, and biological properties of the soil-solute system play an important role. Present study indicates that the advection in soils is dependent on the state of the soil and, in particular, on its degree of saturation. The effect of pore structure on the advection process has also been demonstrated. The trends of experimental data indicate that modeling of models may be valid only for saturated soils.     

Electrosurgical loop procedures in ambulatory gynecology]

The article gives a survey of the new electrosurgical excision procedures that are gaining widespread use in office gynaecology in the nineties. A special emphasis is put on the easy learning procedures, relatively low cost of equipment and the results, which seem to match the results of cold-knife- and laser-conization. The advantages and pitfalls of the see-and-treat principle are discussed and the indications, other than cervical intraepithelial neoplasia, are mentioned.     

Intrauterine growth restriction: identification and management

Intrauterine growth restriction (IUGR) is a common diagnosis in obstetrics and carries an increased risk of perinatal mortality and morbidity. Identification of IUGR is crucial because proper evaluation and management can result in a favorable outcome. Certain pregnancies are at high risk for growth restriction, although a substantial percentage of cases occur in the general obstetric population. Accurate dating early in pregnancy is essential for a diagnosis of IUGR. Ultrasound biometry is the gold standard for assessment of fetal size and the amount of amniotic fluid. Growth restriction is classified as symmetric and asymmetric. A lag in fundal height of 4 cm or more suggests IUGR. Serial ultrasonograms are important for monitoring growth restriction, and management must be individualized. General management measures include treatment of maternal disease, good nutrition and institution of bed rest. Preterm delivery is indicated if the fetus shows evidence of abnormal function on biophysical profile testing. The fetus should be monitored continuously during labor to minimize fetal hypoxia.