“Clinical Applications of the Transvaginal Ultrasound Exam for Obstetric-Gynecologic Emergencies”

For decades, investigators have sought a strategy for finding ovarian cancer early enough to reduce the risk of dying of ovarian cancer. In this issue of the Journal, Lim et al. (1) report on their study in which women answered a dozen simple questions such as whether they felt pelvic or abdominal pain in the recent past and, if so, when, how frequently, and how severely. Symptom indices like this are being promoted as easier or better ways to find ovarian cancer early, under the assumption that early therapy can achieve a better outcome than if the women wait until more or worse symptoms prompt them to see a physician. The study revealed that symptom indices as ovarian cancer screeners can be sensitive to the presence of cancer in the period between 3 and 14 months before clinical diagnosis. On the other hand, they were not highly specific because a substantial fraction of women without disease registered as “positive.” Furthermore, these attractively simple screeners showed a disappointing capacity to find cancer early, largely because the symptom(s) arose close to the time of diagnosis. The study design permits no calculation of years of life that might have been saved or lost if such screeners actually were used—only a large and expensive randomized trial would do that—but clinical gains likely would be minor, and many women would undergo unnecessary diagnostic procedures to assure that they are cancer free. This sobering news follows hard on the heels of a large US randomized trial finding no benefit, and indeed some harm, to women who were screened annually with a transvaginal ultrasound exam and a CA-125 blood test compared with a usual care control group (2). It is plausible that other markers could perform better, but here too, the results so far suggest caution. One serum marker, HE4, performs better than does ultrasound as a second-line screen following CA-125 (3), though it also suffers from bad timing: It spikes relatively late in the year before diagnosis (4). Furthermore, panels of other markers, some of which are in commercial use, did quite well in initial reports but completely failed as a screening method in confirmatory studies ( 5). Why is the development of a sensitive and specific screening method to detect ovarian cancer early so hard? The biology of ovarian cancer, the arithmetic of screening, and the clinical characteristics of the disease and its treatment collude to make it difficult to find ovarian cancer early enough to matter. For instance, we now suspect that many ovarian cancers arise in the fallopian tubes. The cancer may stay there for months or years before either spreading or migrating to the ovaries, with unknown effects on serum levels of any biomarkers. Fortunately, ovarian cancer occurs only rarely, but it follows that even a small fraction of false-positive test results will produce many dangerous and costly follow-up procedures. Most importantly, the clinical characteristics of ovarian cancer pose some simple but profound challenges. Because of the location of the ovaries deep in the pelvis, symptoms seldom announce the presence of disease when it is still in its earliest stages. The symptoms used to derive the indices in this observational study by Lim et al. (1) are most often associated with more advanced stage III and IV disease, and overall, 68% of cancers are stage III or IV at presentation (6). Bowel or urinary symptoms or bloating related to malignant ascites or a palpable mass all suggest a substantial tumor burden. At times, a large mass that is still confined to one ovary can cause these symptoms and will still be amenable to primary surgical removal. However, this scenario represents only a minority of early-stage disease. If a 1-cm mass contains approximately 10 9 cells, it will often take several times that mass to actually cause clinical symptoms. Although it is true that the ability to surgically debulk ovarian cancer to a residual nodule of less than 1 cm—a tumor size that is associated with better responses to chemotherapy and overall longterm outcomes—the underlying biology of the disease may well be more important. Tumor grade is an important variable in determining ability to maximally debulk the tumor and response to cytotoxic chemotherapy. The potential for poor outcomes even with small tumors is seen in other malignancies. In breast cancer, very small tumors with four or more lymph nodes involved have a worse prognosis compared with larger node-negative tumors that would be more likely to present with

478: Should we repeat the cervical ultrasound assessment to predict preterm birth? (COLIBRI study)

Interstitial pregnancy (IP) accounts for 2% of all ectopic pregnancies and has a mortality rate of 2–2.5%. The diagnosis is made by a transvaginal ultrasound and the treatment can be medical or surgical. We report the case of a 36-year-old primigravida who was 6 + 5 weeks pregnant, diagnosed with interstitial pregnancy by ultrasound, who had a very high serum β-hCG level (31,298 mIU/mL) and wanted to preserve her fertility. The patient was treated with one dose of mifepristone and a double dose of methotrexate since the decrease in the β-hCG serum level was less than 15% after the first dose. At the beginning, medical therapy was effective, as no embryonal cardiac activity was detected and serum β-hCG levels decreased early, but on the 20th day of hospitalization, the patient underwent surgery for her clinical symptoms and the evidence of free fluid in the Douglas pouch at a transvaginal ultrasound exam. Our experience showed that medical treatment should be considered, especially in women wishing to preserve their fertility. Further studies are needed to establish a standardized protocol and maybe a clinical score that can be useful in predicting the patients in which medical therapy could be most successful.

Reproductive aging and variability in the ovarian antral follicle count: application in the clinical setting

Progesterone is a steroid hormone synthetized from pregnenolone, a derivate of cholesterol, produced by the yellow body of the ovary and by the placenta during pregnancy. It is crucial for the evolution of the pregnancy, from preconception until delivery. It prepares the endometrium for implantation, supresses the immune response, inhibits the myometrium�s contractility and it can also make the myometrium sensitive to the action of beta-mimetic tocolytics. The vaginal administration of progesterone in various doses has proved effective in preventing premature birth in pregnant women with short cervix � 25mm during transvaginal ultrasound exam.

Society for Maternal-Fetal Medicine Special Statement: Reducing the risk of transmitting infection by transvaginal ultrasound examination

Current studies show that about half of transgender and gender-diverse (TGD) people wish to have children in the future. TGD patients who pursue gender-affirmation interventions must be aware of the impact that various treatments can have on fertility, as gender-affirming care through medical or surgical treatment can limit or alter reproductive potential. Many medical professional societies encourage providers to educate and counsel patients about the consequences of treatment and viable options for fertility preservation (FP) as early as possible, though patients may not be aware of all the family formation methods available. There is a significant need for a tool that thoroughly details not only the various opportunities for parenthood but the perceived cost, rates of success, and risks associated with each option. A fertility decision-aid would allow for a more robust informed consent process and shared decision-making for all individuals pursuing gender-affirming care.

To ascertain the overall frequency of obtaining chorionic villi (CV) in patients with indeterminate transvaginal ultrasound (US) examinations who have had a dilatation and evacuation (D+E) procedure performed, to determine whether the frequency of obtaining CV is dependent on whether the endometrial cavity is empty at US, and to determine the likelihood of ectopic pregnancy in patients without CV after D+E and with or without an empty endometrial cavity at US. A retrospective review was made of consecutive ED patients presenting to an urban teaching hospital from August 1991 through August 1997 with abdominal pain or vaginal bleeding and a positive beta-human chorionic gonatropin (beta-hCG) test. Patients who had a transvaginal US that was read as indeterminate (no extrauterine findings of ectopic pregnancy, and no intrauterine fetal pole or yolk sac) and who had a D+E performed within 48 hours of the ED visit were eligible. US exams were subdivided into two groups, those with empty endometrial cavities and those with endometrial cavities that contained fluid, echogenic material, or sac-like structures. The presence or absence of CV was based on the official pathology report. Patients were excluded if pathology results were not available. A total of 255 patients met eligibility criteria. Of these, pathology results were not available for five patients. Of the remaining patients, 177 of 250 (70.8%: 95% CI = 64.7% to 76.3%) had CV identified in the pathology specimen. The difference in the frequencies of obtaining CV in those with empty endometrial cavities (35/78; 44.9%: 95% CI = 34% to 56%) vs. those without empty endometrial cavities (142/172; 82.6%: 95% CI = 76% to 88%) was significant (p<0.001). Ectopic pregnancy was diagnosed in 17 of 42 (40.0%) with empty uteri at US and no CV at pathology vs 5 of 26 (19.2%) in whom the uterus was not empty and no CV were obtained (p = 0.07). In symptomatic patients with indeterminate transvaginal ultrasound exams, CV will be identified after D+E in approximately 70% of cases. Although CV were found with increased frequency when the endometrial cavity was not empty, still almost half of the patients with empty uteri had villi identified. Finally, although the frequency of ectopic pregnancy was higher in the patients with empty uteri and no CV at D+E, vs. those without an empty uterus and no CV, this difference did not reach statistical significance.

Simple SummaryHorses are high-level athletic athletes prone to musculoskeletal injuries. Tendon/ligament injuries are the most frequent types of injuries which that are very difficult to treat. Instead of tissue regeneration, usually, fibrous scar tissue develops which leads to decreased functionality of the injured area and threatens the participation of sport horses. The aim of regenerative medicine is to find a treatment that promotes tissue regeneration and that allows the equine patient to return to the same level of athletic performance in the shortest time period possible. In this study, we developed a solution of equine synovial membrane stem cells and autologous serum, to be injected at the lesion site to promote tissue regeneration. We describe the processes of tissue collection, preparation, isolation of synovial stem cells, expansion, culture, cryopreservation, and posterior preparation with autologous serum. The solution was tested in 16 tendons and ligaments of equines. After treatment, all equine patients underwent a physical rehabilitation program and were monitored with physical and ultrasonographic exams. The results were very promising, and thus, support the use of equine synovial stem cells and autologous serum in the treatment of tendonitis and desmitis.Tendon and ligament injuries are frequent in sport horses and humans, and such injuries represent a significant therapeutic challenge. Tissue regeneration and function recovery are the paramount goals of tendon and ligament lesion management. Nowadays, several regenerative treatments are being developed, based on the use of stem cell and stem cell-based therapies. In the present study, the preparation of equine synovial membrane mesenchymal stem cells (eSM-MSCs) is described for clinical use, collection, transport, isolation, differentiation, characterization, and application. These cells are fibroblast-like and grow in clusters. They retain osteogenic, chondrogenic, and adipogenic differentiation potential. We present 16 clinical cases of tendonitis and desmitis, treated with allogenic eSM-MSCs and autologous serum, and we also include their evaluation, treatment, and follow-up. The concerns associated with the use of autologous serum as a vehicle are related to a reduced immunogenic response after the administration of this therapeutic combination, as well as the pro-regenerative effects from the growth factors and immunoglobulins that are part of its constitution. Most of the cases (14/16) healed in 30 days and presented good outcomes. Treatment of tendon and ligament lesions with a mixture of eSM-MSCs and autologous serum appears to be a promising clinical option for this category of lesions in equine patients.

Ultrasound frontiers are infinitive and some recent developments are discussed in this review. The author aims to provide the reader with the definition of 3D Doppler and its potential clinical applications. It also describes automatic fetal biometry and discusses clinical potentials of handheld ultrasound. The rapid development of these new sonographic techniques will continue to enlarge the scope of ultrasound applications in obstetrics and gynecology. 3D Doppler is a unique technique that enables assessment of vascular signals within the whole investigated area. Homodynamic changes included in the process of placentation are one of the most exciting topics in the investigation of early human development. The measurement errors produced by automated fetal biometry translate into very small errors regarding gestational age of the fetus. The automation of ultrasound measurements has great potentials in improving productivity and patient throughput, enhancing accuracy and consistency of measurements and reducing the risk of repetitive stress injuries users. Handheld ultrasound exam is reliable in making initial diagnosis required by the limited ultrasound exam in obstetrics and gynecology. Objectives Define 3D Doppler and its potential clinical applications Describe automatic fetal biometry Discuss clinical potentials of handheld ultrasound

Background: Displaced Abomasum is known for being on of the main illnesses that affect milking cows. Increase in diagnosis of this illness is due to advancement in diagnosis techniques. Increase in incidence of this illness can be explained by genetic selection of animals with high production, breed systems and changes to the diet with a higher level of protein. For laparoscopic treatment, several surgical changes were performed to optimize the procedure and thus achieve better results. The main purpose of this study was to evaluate applicability of the ventral laparoscopic abomasopexy technique, using surgical clamps attached to the suture thread, to milking cows.Materials, Methods &amp; Results: Six adult cows were placed under anesthesia with isoflurane and placed in dorsal decubitus. Animals were kept with no water for 24 h and no food for 48 h. Four laparoscopic accesses were performed. The first one was created with the intention of inspecting the abdominal cavity and the remaining three for access of surgical instruments. Serous membrane of the abomasum was cauterized, combined with suture threads and placed at the greater abomasal curvature. The free part of suture threads was kept out of the abdominal cavity and after traction of the abomasum against the abdominal wall was tied to the skin. Ultrasound exam was performed for abdominal evaluation after abomasopexy. Anesthesia time and surgery time were recorded and analyzes through average and standard deviation (SD). The average anesthesia time recorded was 94 min (SD 14.63 min) and average surgery time was 51 min (SD 14.71 min). The fasting period was considered adequate, however all animals had to undergo intubation with orogastric tube to drain liquids and gas during the procedure. Four of the six animals had lineal adhesion. Three of the four animals that had adhesion did not keep the abomasum at the retroperitoneal area, however viscera movement was stopped in the abdominal cavity.Discussion: Abomasopexy through laparoscopy is a safe technique, especially when compared with other invasive methods of abomasopexy. However, to perform this type of surgery availability of adequate equipment and a well trained surgical team are required. This study was performed at a surgery room under full anesthesia. In a field situation, the veterinarian can have some difficulties but such adversities must not be considered and impediment for performance of surgery on the field as its performance is possible. Even though surgical clamps were small, they were considered adequate for what was suggested. The applied 0 degree laparoscopic optic presented restrictions for cavity inspection, therefore we believe that an optical lenses with 30 degree angle could facilitate this laparoscopy inspection. To induce greater and more lasting adherence we suggest cauterizing a greater area of the serous membrane of the abomasum. We also suggest not performing this procedure during lactation peak, when fasting and surgery can cause economic losses. Complications associated with this technique could not be avoided. The technique has shown favorable results, but its clinical applicability depends on application on animals subjected to the conditions of a milk production cycle.

Influence of Data Parsing on Contrast Enhanced Ultrasound Exams

Cryopreserved Blastocysts Using Vitrification Protocol Give Excellent Pregnancy and Implantation Rates After Thawing

Zone-0 Thoracic Branched Endograft Implantation in a Previously Debranched Aorta for Symptomatic Type 1A Endoleak.

Chapter 26 - Bladder