Nicolette Caccia

The T cell receptor β chain genes are located on chromosome 6 in mice and chromosome 7 in humans

Homologous clones that encode the beta chain of the T cell antigen receptor have been isolated recently from both murine and human cDNA libraries. These cDNA clones have been used in connection with interspecies hybrid cell lines to determine that the murine T cell receptor gene is located on chromosome 6 and the human gene on chromosome 7. In situ hybridization confirms these data and further localizes these genes to band B of chromosome 6 in the mouse and bands 7p13-21 in the human genome. The organization of the T cell antigen receptor J beta gene segments and C beta genes appears to be conserved, since very few intraspecies polymorphisms of restriction fragment length have been detected in either mouse or human DNA.

Trends in menstrual concerns and suppression in adolescents with developmental disabilities.

PURPOSE Demonstrate changes in methods of menstrual suppression in adolescents with developmental disabilities in a recent 5-year cohort compared with an historical cohort at the same hospital. METHODS Retrospective cohort study of patients with physical and cognitive challenges presenting for menstrual concerns at an Adolescent Gynecology Clinic between 2006 and 2011 compared with a previous published cohort (1998 to 2003). RESULTS Three hundred patients with developmental disabilities aged 7.3 to 18.5 years (mean 12.1 ± 1.6) were analyzed. Caregiver concerns included menstrual suppression, hygiene, caregiver burden, and menstrual symptoms. Ninety-five percent of patients had cognitive disabilities, 4.4% had only physical impairments. Thirty-two (31.7) percent of patients presented premenarchally. The most commonly selected initial method of suppression was extended or continuous oral contraceptive pill (OCP) (42.3%) followed by patch (20%), expectant management (14.9%), depot medroxyprogesterone acetate (DMPA) (11.6%), and levonorgestrel intrauterine system (LNG-IUS) (2.8%). Published data from 1998 to 2003 indicated a preference for DMPA in 59% and OCP in 17% of patients. The average number of methods to reach caregiver satisfaction was 1.5. Sixty-five percent of initial methods were continued. The most common reasons for discontinuation were breakthrough bleeding, decreased bone mineral density, or difficulties with patch adherence. Second-choice selections included OCP (42.5%), LNG-IUS inserted under general anesthesia (19.2%), DMPA (17.8%), and patch (13.7%). CONCLUSIONS Since identification of decreased bone mineral density with DMPA and emergence of new contraceptive options, use of extended OCP or patch has surpassed DMPA for menstrual suppression in our patient population. LNG-IUS is an accepted, successful second-line option in adolescents with developmental disabilities.

Retrospective Review of Unintentional Female Genital Trauma at a Pediatric Referral Center

Unintentional female genital trauma is a complaint commonly seen and managed through the emergency department. The purpose of this study was to review all unintentional female genital trauma evaluated at The Hospital for Sick Children for 3.5 years to determine the factors associated with gynecologic consultation and need for operative repair. Methods: One hundred five patients were identified by health record coding. Data were extracted to study factors associated with gynecologic consultation and operative repair. Statistical analyses were performed to evaluate the significance of these associations. Surgical choices were also evaluated. Results: Mean age was 5.60 years. Mean time to presentation was 7.05 hours. Straddle injury was the most common mechanism (81.90%), and only 4.76% injuries were penetrating. Of the 105 patients, 48.57% consulted the gynecology section, 19.05% were taken to the operating room, and 6.66% were treated under conscious sedation. Overall, 20.95% required surgical repair. The most common complication was dysuria. Six patients had other injuries, the most common of which were pelvic fractures related to trauma. Factors significantly associated with gynecologic consultation and operative management included older age, transfer to our institution, shorter time to presentation, laceration-type injury, hymenal injury, and larger size of injury. Straddle injuries were significantly less likely to be taken to the operating room. When cases were stratified by a surgeon, there were no significant differences in management. Conclusions: Unintentional female pediatric genital traumas most commonly result from straddle injuries. Most injuries are minor, and in this cohort, only 48.57% received gynecologic consultation and 19.05% required operative management. Future prospective studies would be useful to better evaluate the efficacy of surgical choices.

Hysteroscopic unification of a complete obstructing uterine septum: case report and review of the literature.

OBJECTIVE To report a case of complete obstructing uterine septum repaired in a minimally invasive manner by operative hysteroscopy under laparoscopic guidance. A complete obstructing uterine septum is a rare congenital abnormality. To date, management of such abnormalities has traditionally been by metroplasty. DESIGN Case report and review of the literature. SETTING Pediatric and adolescent gynecology service at a tertiary care hospital. PATIENT(S) A 16-year-old nulligravid presented with severe, persistent dysmenorrhea and a history of significant endometriosis. Imaging initially suggested a functional, noncommunicating uterine horn, but magnetic resonance imaging review confirmed a complete obstructing septate uterus. INTERVENTION(S) The patient was managed by menstrual suppression until the time of surgery. The septum was resected by operative hysteroscopy under laparoscopic guidance. The procedure was without complication. MAIN OUTCOME MEASURE(S) The patient recovered well and resumed spontaneous menses without dysmenorrhea. RESULT(S) A second-look hysteroscopy 4 months later confirmed patency of the previously obstructed side and allowed the opportunity to complete the resection of the septum. CONCLUSION(S) Operative hysteroscopy is an effective and safe minimally invasive technique to manage the rare complete obstructing uterine septum. Hysteroscopy is less invasive than traditional metroplasty and is associated with easier recovery. Additionally, there is no uterine scar and thus less implication for future fertility. Further series of such procedures are required to offer greater experience and proof of safety of this approach.

Repeat screening for sexually transmitted infection in adolescent obstetric patients.

OBJECTIVE To determine if repeat screening for sexually transmitted infection is appropriate for adolescent obstetric patients and to identify any risk factors associated with increased risk of contracting a sexually transmitted infection (STI) during pregnancy. METHODS We conducted a retrospective review of the medical records of adolescent obstetric patients seen over a five-year period in the Young Prenatal Program at the Hospital for Sick Children (Toronto, Ontario). RESULTS Between January 2003 and December 2007, 201 patients with 211 pregnancies attended the Young Prenatal Program. Of the 211 pregnancies reviewed, all patients had screening at baseline for HIV, syphilis, hepatitis B, chlamydia, gonorrhea, and trichomonas; 173 patients were screened in the third trimester, two were tested at another point in the pregnancy because of symptoms, and 161 were screened at their postpartum visit. In 53 pregnancies, STI was diagnosed either during pregnancy or postpartum. Fourteen patients had multiple sexually transmitted infections for a total of 71 infections. Thirty-four infections were diagnosed at baseline, 15 in the third trimester, two because of symptoms, and seven were diagnosed postpartum. In patients who did not develop an STI during pregnancy, the previous use of contraception (excluding condoms), being in a relationship with the babys father, and living with their partner were identified as significant protective factors against STI. There was a trend towards significance for contracting an STI in patients with a history of abuse, in those with a higher than average number of sexual partners, and in those with a younger than average age of coitarche. CONCLUSION Sexually transmitted infections were diagnosed in 25.1% of adolescent pregnancies (53/211) in our cohort. Of the 71 sexually transmitted infections diagnosed, 22.5% (16/71) were diagnosed on routine third trimester screening. Because of the high rates of STI and the small number of identified risk factors, routine repeat screening in the third trimester for chlamydia, gonorrhea, and trichomonas is warranted in pregnant adolescents.

Obstetrics and gynaecology training in Europe needs a next step

Changing societal demands on doctors necessitate changes in the training of gynaecologists. Adapting this training will need well-thought-out and comprehensive planning that addresses the needs of the major stakeholders: society, patients, and doctors themselves. Doctors need to be cognizant of societal issues such as rapidly rising healthcare costs and budgetary crises, and be able to participate in the solutions. This demands effective medical leadership, which has been a neglected area in postgraduate training. It has become increasingly evident that a holistic view of the patient rooted in proper teamwork and systems-based practice is essential to provide patient-centered care. Specialists need to expand their skill set to participate in this kind of care. Furthermore, the feminisation of the medical profession and a new generation of doctors rejecting the constraints of the traditional model of medical care introduce new professional perspectives. This manuscript briefly reviews the challenges faced in the training of European gynaecologists in an effort to provoke discussion about how to best train the gynaecologists of the future.

Pediatric synchronous bilateral ovarian torsion: a case report and review of the literature

Ovarian torsion is a surgical emergency that can present with a variety of symptoms and hence is difficult to diagnose. We present the first case of a pediatric synchronous bilateral ovarian torsion in ovaries without pathology and review its presentation, diagnosis, treatment, outcome, and the associated literature.

The α and β Chains of the T-Cell Receptor

The mammalian immune system must be equipped to recognize and eliminate a vast number of different foreign antigens. These antigens must be distinguished from self molecules to ensure that the organism’s own structures are preserved, necessitating a well-regulated network of cells and their products. The immune system can be divided into the closely interacting compartments of nonspecific immunity and specific immunity. Nonspecific immunity is effected by cells such as macrophages and natural killer cells, which eliminate foreign antigen by lytic and digestive processes. These cells, by themselves, cannot distinguish between foreign and self antigens because they are nonspecific, and thus must be closely regulated and directed. This regulation is effected by cells from the specific immune compartment, B and T lymphocytes, which provide the fine tuning of the immune response. These two cell types are very similar in their specific recognition of antigen by means of a diverse clonally distributed repertoire, but differ in the molecules used to mediate their recognition of antigen and the context in which it is recognized. B lymphocytes secrete immunoglobulins and express them on their cell surfaces. These molecules are capable of recognizing both soluble antigen and that on the surface of cells. The portion of the molecule that is not involved in antigen recognition participates in a number of immune reactions, including those involving cells of the nonspecific compartment, that lead to the elimination of antigen (Davies and Metzger, 1983).

Competency-Based Medical Education: The Wave of the Future*

Competency-based medical education (CBME) is a new educational paradigm that will enable the medical education community to meet societal, patient, and learner needs of the 21st century. CBME offers a renewed commitment to both clinical and educational outcomes, a new focus on assessment and developmental milestones, a mechanism to promote a true continuum of medical education, and a method to promote learner-centred curricula in the context of accountability. Accountability is central to CBME, ensuring that graduating practitioners are well-rounded and competent to provide safe and effective patient care. The structure of CBME in obstetrics and gynaecology must be rooted in, and reflect, Canadian practice. Its development and implementation require an understanding of the principles that are the foundation of CBME, along with the involvement of the entire community of obstetricians and gynaecologists and other maternity care providers. We provide here an overview of the basic principles of teaching and learning and the theories underpinning CBME.

Competency-Based Medical Education: Developing a Framework for Obstetrics and Gynaecology

The development of a Canadian competency-based medical education (CBME) curriculum in obstetrics and gynaecology, slated to begin in 2017, must be rooted in, and aligned with, the principles of CanMEDS 2015 and Competence by Design. It must also reflect the unique realities of the practice of the specialty. The Dutch Society of Obstetrics and Gynaecology has been at the forefront of the movement to design and implement competency-based training for obstetrics and gynaecology. The Dutch curriculum represents a practical example of how such a program could be developed. Several CBME curricular initiatives have now also begun across Canada.