Misgav Rottenstreich

Endometriosis-associated malignant transformation in abdominal surgical scar: A Prisma-compliant systematic review

Background: Endometriosis-associated malignant transformation in abdominal surgical scar (EAMTAS) is a very rare and aggressive phenomenon. Our current article aims to provide a clinical overview, focusing on risk factors affecting survival. Methods: We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review based on prior reviews and case reports regarding the phenomenon published as abstracts in English, from January 1980 to November 2016. Overall, we identified 47 cases, and we included another case from our institution. We further contacted previous investigators to receive updated follow-up regarding their patients. We analyzed the data, focusing on risk factors that might affect overall survival. Results: All the patients reported in the literature had a uterine surgery, mainly caesarean section. The median time-lag from first surgery to the diagnosis of cancer was about 19 years. Clear-cell carcinoma (CCC) was the most prevalent histology (67%), followed by endometrioid adenocarcinoma (15%). Most of the patients were treated by extensive surgery and chemotherapy and/or radiation. Overall 5 years survival was about 40%. Median overall survival was 42 months (95% confidence interval of [18.7, 65.3]). Although our review is currently the largest in the literature, we cannot draw any statistical significant results due to the limited number of patients reported. According to univariate Cox-regression models, a tendency toward worse prognosis was shown for 3-year disease-free survival clear cell histologic-type (P = .169), and tumor diameter ≥8 cm in nonclear-cell histology, 18 months postdiagnosis (P = .06). Conclusion: EAMTAS is a rare and aggressive disease. It is mostly related to cesarean section scars and is diagnosed many years postsurgery. Clear-cell histology tends to endure from the worse prognosis. The treatment is mainly extensive surgery and adjuvant chemotherapy and/or radiotherapy.

Unintended pregnancies among women serving in the Israeli military

OBJECTIVE The objective was to identify the prevalence of and variables associated with unintended pregnancy among young, unmarried women serving in the Israeli military. STUDY DESIGN We performed a retrospective cohort study of unmarried women drafted by the Israeli military between 2013 and 2015 at the age of 18 years. We used multivariable logistic regression to examine associations between unintended pregnancy and womens education, IQ, immigration status, country of origin, neighborhood socioeconomic status and history of psychiatric illness. RESULTS Most women (n=127,262) did not become pregnant while serving in the Israeli military. Unintended pregnancy was reported by 2365, with an additional 6 women reporting pregnancy resulting from sexual assault and 5 an intended pregnancy. Annual rates of unintended pregnancy among young women serving in the Israeli military declined from 1.69% in 2013 to 1.56% in 2014 and 1.33% in 2015. In multivariable models, unintended pregnancy was more common among women soldiers who had not graduated from high school (adjusted relative risk [RR], 5.3; 95% confidence interval [CI], 4.69-6.04) and those who were first-generation immigrants (adjusted RR, 2.1; 95% CI, 1.90-2.35). CONCLUSION Unintended pregnancy is rare among women serving into the Israeli military. IMPLICATIONS Increasing contraceptive use among women who have not graduated from high school may further reduce rates of unintended pregnancy among women serving in the Israeli military.

The clinical findings in young adults with acute scrotal pain

BACKGROUND Acute scrotal pain (ASP) is a common symptom of young adults. Testicular torsion is the most important diagnosis in these cases. It is a medical emergency in which the diagnosis must be made rapidly to prevent testicular loss. This requires a high index of clinical suspicion and prompt surgical intervention. This study was conducted to examine the spectrum of diagnoses in young man with ASP in a prehospital setting, the frequency of significant diagnoses, and their outcomes. METHODS The medical records of young adults in their obligatory military service presenting with ASP to primary care clinics from 2004 to 2014 were reviewed using the keywords: pain, testis, torsion, and orchialgia. Anamnestic data, physical findings, primary care physician decisions, and final outcomes were analyzed. RESULTS A total of 9922 medical visits were recorded. Idiopathic scrotal pain, varicocele, scrotal trauma, and genital tract infections were the most common diagnoses. In 3 visits (0.03%), testicular cancer was diagnosed. Testicular torsion was the etiology of ASP in only 12 (0.12%) visits, and 60% the testes were salvaged. The mean duration of symptoms in the salvaged group was 6.33 hours; and in the nonsalvaged group, 44 hours. CONCLUSIONS Testicular torsion is the etiology of ASP in only 0.12% of the visits to the primary care clinic. Patient delay before attending the primary care is responsible for most of the testes lost. Patient education in addition to high index of suspicion of primary care physicians is needed for salvage of more testicles.

Needle Thoracotomy in Trauma

Tension pneumothorax is one of the leading causes of preventable death in trauma patients. Needle thoracotomy (NT) is the currently accepted first-line intervention but has not been well validated. In this review, we have critically discussed the evidence for NT procedure, re-examined the recommendations by the Advanced Trauma Life Support organization and investigated the safest and most effective way of NT. The current evidence to support the use of NT is limited. However, when used, it should be applied in the 2nd intercostal space at midclavicular line using a catheter length of at least 4.5 cm. Alternative measures should be studied for better prehospital management of tension pneumothorax.

Doxycycline induced oesophageal ulcers in a navy ship crewmember

A healthy 25-year-old crewmember of a navy ship was diagnosed with suspected pneumonia and prescribed 100 mg twice a day of doxycycline for 10 days. During the 7th day of treatment the patient joined his navy ship to sail aboard and 2 days later, immediately after taking the doxycycline capsule, he felt a forceful pain in the median chest which was followed with odynophagia of both solid foods and liquids. The patient adhered to the administration guidelines of the doxycycline, except drinking 330 mL of beer, 3 h before taking the capsule. A working diagnosis of atypical chest pain, possibly due to oesophagitis, was made. The patient was advised to fast and rest and treatment with intravenously (IV) H2-receptor antagonist, clear fluids and analgesics was started. Later on, due to lack of improvement in the patients status and the potential risk of future deterioration, a decision was made to evacuate the patient to a hospital. Gastroscopy, revealed 3 ulcers in the mid-oesophagus and the patient was hospitalised for treated of IV antacids and fluids with gradual improvement. This case emphasizes the limitation of diagnosing and treating a common side effect in the middle of the sea and the potential risk in taking medications with alcohol.

The value of a registry negative urine pregnancy test for the prediction of a future unintended pregnancy among young women

Abstract Background: Performance of urine pregnancy test in general adolescents’ clinic reflects caregiver or woman’s concern that there might be a pregnancy. We aimed to assess whether young-unmarried women in whom a negative urine pregnancy test was registered would be at increased risk of a future unintended pregnancy. Methods: The study cohort included consecutive women drafted by the Israeli military between 2013 and 2015. The risk of unintended pregnancy was compared between women with a negative urine pregnancy test (n = 2774), the study group, and those in whom urine pregnancy test was not carried out (n = 126,659), the control group. Results: During the study period, 2147 (1.7%) women experienced an unintended pregnancy. The risk of unintended pregnancy was significantly higher in patients in whom a past pregnancy test was negative 4.3% (n = 118), as compared with the control group 1.6% (n = 2028) (odds ratio [OR], 2.7; 95% confidence interval [CI], 2.23–3.26). In multivariate analysis history of a negative pregnancy test results was an independent predictor for a future unintended pregnancy (adjusted OR, 2.0; 95% CI, 1.63–2.52). Conclusions: A history of a negative pregnancy test among young conscripted women is a significant risk indicator for a future unintended pregnancy. Directed efforts should be made in this particular vulnerable group of patients.

Recurrent unintended pregnancies among young unmarried women serving in the Israeli military

BackgroundUnintended pregnancy is a major public health problem with known risk factors, however, little is known about the prevalence of variables associated with recurrent unintended pregnancy (RUP) among young, unmarried women.MethodsA retrospective cohort study of unmarried women aged 18–21 serving in the Israeli military between 2013 and 2015. Multivariable logistic regression analysis was used to examine associations between RUP and women’s education, IQ, immigration status, country of origin, socioeconomic status and history of psychiatric illness.ResultsOf 129,638 women drafted by the Israeli military during the study period, 1720 women with unintended pregnancies had a follow up period of at least a year. Three hundred and eighty-nine of them had RUP (22.6%). Multivariable models comparing women with no unintended pregnancies and women with RUP revealed that RUP was more common among (adjusted relative risk; 95% confidence interval) women who had not graduated from high school (6.9; 4.99–9.55), who had low (90–99) IQ scores (3.9; 2.88–5.39) those reporting Africa as the country of origin (2.5; 1.37–4.59) and those from a lower socioeconomic neighborhood (1.6; 1.18–2.05). Multivariate regression modeling comparing women with single unintended pregnancies and women with RUPs showed that recurrent unintended pregnancy was more common among women who had not graduated from high school (3.2; 2.04–4.84) and those who had a low (90–99) IQ score (1.9; 1.32–2.61).ConclusionRate of RUP is high among women serving in the Israeli military. These women have unique epidemiological characteristics. This may serve in identifying populations at high risk and thus may enable policy maker to offer at least to this population Long-Acting Reversible Contraception (LARC) methods. We encourage policy makers to consider the provision of LARC methods to all servicewomen who had an unintended pregnancy.

Clinical characteristics, neonatal risk and recurrence rate of gestational thrombocytopenia with platelet count <100 × 109/L

OBJECTIVE Gestational thrombocytopenia (GT) accounts for 75% of cases of thrombocytopenia in pregnancy. In most cases of GT, thrombocytopenia is mild (100-150 × 109/L) and has no consequences for either the mother or the fetus. We aimed to investigate the characteristics, neonatal risk and recurrence rate of GT with a platelet count <100 × 109/L. STUDY DESIGN We reviewed the records of women who delivered during 2006-2016 at a large tertiary care university hospital, and who had platelet count <100 × 109/L during pregnancy. RESULTS Of 97 pregnancies in which platelet count lower than 100 × 109/L was encountered, 66 (68%) were diagnosed as GT and 31 (32%) as new-onset immune-thrombocytopenic purpura (ITP). The proportions of women with onset of thrombocytopenia in early pregnancy (P = 0.004) and a lower maternal nadir platelet count (P = 0.01) were higher among those with new-onset ITP than GT. There was no difference in the rate of neonatal thrombocytopenia (<100 × 109/L) between those with newly diagnosed ITP and GT (16.1% vs. 10.6%, P = 0.51). Among women with GT, the rate of neonatal thrombocytopenia was higher in those who experienced antepartum bleeding (P = 0.009) and in whom the onset of thrombocytopenia was in early pregnancy (P = 0.002). Of 40 subsequent pregnancies, a recurrence of GT (<100 × 109/L) was encountered in 22 (55%), with similar maternal and perinatal outcomes compared to the initial pregnancy. CONCLUSION The risk of neonatal thrombocytopenia was substantial, with no difference found between those with GT and new-onset ITP. The recurrence rate of GT was high in subsequent pregnancies.

Isolated Torsion of Accessory Fallopian Tube in a Young Adolescent

BACKGROUND Accessory fallopian tube is a rare anatomical variation, which might rarely cause gynecological complications such as infertility, ectopic pregnancy, cystic swelling, and pyosalpinx. It is usually diagnosed by surgeons during diagnostic laparoscopy for other purposes. We present a rare case of isolated accessory tube torsion in a young adolescent. CASE A 16-year-old virgin teen presented with a 24-hour history of aggravating right lower-quadrant abdominal pain and nausea without vomiting or fever. On examination she had right lower quadrant abdominal tenderness with no peritoneal signs. On pelvic ultrasound a right corpus luteum cyst was suspected, but right adnexal torsion could not be ruled out. On laparoscopy, torsion of the right accessory tube was diagnosed. Because of its ischemic and bluish appearance it was removed. The postoperative course was uneventful. Pathology confirmed the diagnosis. SUMMARY AND CONCLUSION Torsion of an accessory fallopian tube is rare. An English literature search showed that the current case is the third reported overall and the first in a young adolescent. Because of the rarity of this congenital variation, and the low suspicion index for its existence, the diagnosis of accessory tube is often missed. Preventive removal of such findings should be considered but weighed against its possible surgical complications.