Sertoli-Leydig Cell -A Rare Male Hormone Producing Ovarian Tumor

Sertoli-Leydig cell tumor (SLCT) of ovary is an unusual neoplasm that belongs to a group of sex cord-stromal tumors of ovary. It accounts for less than 0.5% of all primary ovarian neoplasms. We report a case of primary intermediate ovarian Sertoli-Leydig cell tumor (SLCT) involving the left ovary in a 32-year-old nulliparous woman who presented with history of secondary amenorrhea for 8 months, hirsutism, and voice change

Emergency Obstetrical Hysterectomy

This study was designed to determine the incidence, indications and complications of emergency obstetrical hysterectomy. The cases were analyzed from January 2003 to December 2008 in the obstetric unit of Fatima Hospital, Baqai Medical University, Karachi. The Demographic and clinical variables were obtained from the maternal records. Incidence of emergency obstetrical hysterectomy was found out to be 1:238 deliveries. Out of these 6(40%) of patients were in the age group between 31-35 years. Average age was 31years. Multiparous patients were 7(46.6%) and grand multiparous were 6(40%) with mean parity of 5. The most common indication leading to obstetrical hysterectomy was Atonic uterus causing postpartum hemorrhage in 7(46.6%) of patients. Ruptured uterus was responsible for this procedure in 2(13.3%) patients. Regarding complications, deep venous thrombosis developed in 1(6.6%) patient. The maternal deaths occurred in 3(20%) patients. The incidence of emergency obstetrical hysterectomy is not very much high. Majority of the patients were referred by traditional birth attendants (TBA’s) with complications of labor and delivery. To further reduce the incidence, education of TBA’s and early referral along with community awareness are essential

Immediate Post-Placental Insertion versus Interval Insertion of Intrauterine Devices for Contraception

Objective: To compare the frequency of uterine perforation, expulsion and pelvic infection rate of multiload 375 in womenof immediate post-placental (IPP) insertion versus interval insertion (I).Materials and Methods: This Quasi-experimental study was carried out in the Department of Obstetrics & Gynecology, PNSSHIFA Hospital Karachi from 6th October 2008 to 5th October 2009. Fifty patients were selected by consecutive samplingtechnique for Group A (immediate post-placental insertion of multiload 375). Fifty women for group B (interval insertion ofmultiload 375) were selected by simple random sampling during their postnatal follow-up visit. Post- insertion follow up visitwas done within six weeks. The results were analyzed by SPSS version 12 and expressed in frequencies and percentages.Pearson’s Chi-square test was used as the test of significance.Results: Mean age of women in group A was 29.02 ± 2.97 and in group B it was 31.24 ± 5.59 years. Multiparous women optedfor IUD in both groups (48% in group A versus 44% in group B). IUD expulsion was 14% & 18% in group A & B respectively.While infection rate was 4% in group A and 2% in group B. Statistically non significant (P>0.05) results were found. No caseof uterine perforation was noted in both the groups.Conclusion: Although both methods have almost same complication rate but for non compliant women IPP insertion of anIUD is a convenient selection for contraception.Keywords: Intrauterine device (IUD), Immediat

Importance of estimation of follicular output rate (FORT) in females assisted by intracytoplasmic sperm injection

Background: We aimed to estimate pregnancy outcome after ICSI in terms of oocyte parameters, embryo quality, endometrial thickness, hormone and cytokine levels in women stratified on the basis of follicular output rate (FORT).Methods: Quasi experimental design was carried out after approval from “Ethical review board of Islamabad clinic serving infertile couples” from July 2010 to August 2013. One thousand and fifty females were selected with the criteria of age between 21-40 years, infertility of more than 2 years, body mass index of 18-35 kg/m2, menstrual cycle of 25 ± 7 days, both ovaries present with normal uterine cavity, serum FSH levels less than 8 IU/ml and normal thyroid-stimulating hormone levels. Females on short agonist or antagonist protocol with diagnosis of polycystic ovarian syndrome, fibroids or in their male partner sperms retrieved by testicular biopsy were excluded from the study. Down regulation of ovaries was followed by controlled ovarian stimulation, Ovulation Induction (OI), oocyte pick up, in vitro fertilization, Embryo Transfer (ET) and confirmation of pregnancy was done by serum beta hCG of more than 25 mIU/ml and  cardiac activity on trans vaginal scan. Enzyme linked immuno sorbent assay was used for peak and mid luteal estradiol (E2), progesterone (P) and interleukin I-β estimation on OI and ET days respectively. FORT (ratio of preovulatory follicle count to antral follicle count × 100 on OI day) stratified females into low under the 33rd percentile, medium between the 33rd and the 67th percentile and high above the 67th percentile. Characteristics   of groups were compared by one way analysis of variance.  Results: Females 276 (33%), 288 (34%) and 282 (33%) comprised of low, medium and high FORT groups respectively. The number of retrieved, mature and fertilized oocytes, cleaved embryos, endometrial thickness and number of gestational sacs in the high FORT group was significantly high (P <0.001). High peak and midluteal E2 (P = 0.0025, 0.0001), low P (P = 0.0001) and high peak interleukin-1β (P = 0.0001) was observed in high FORT in comparison with medium FORT with resultant greater number of clinical pregnancies 183 (65%).  Conclusions: The FORT in non PCOS patients may reflect good reproductive outcome after ICSI with maximum clinical pregnancies in high FORT group.

Influence of body mass index and polycystic ovarian syndrome on ICSI/IVF treatment outcomes: A study conducted in Pakistani women

Background: Obesity may establish a crucial barrier for effective fertility treatment in polycystic ovary syndrome (PCOS) females.Objective: To compare results of intra-cytoplasmic sperm injection (ICSI) in females with and without polycystic ovarian syndrome and further appraise the effect of obesity in PCOS females.Materials and methods: A cross-sectional study from June 2015 to July 2016 included non-PCOS and PCOS (recognized by Rotterdam criteria) females who underwent ICSI. The PCOS were further stratified into non-obese and Obese according to the South Asian criteria for body mass index. Results were categorized on the basis of beta-human chorionic gonadotropin (β-hCG) and transvaginal scan into non-pregnant (β-hCG /ml), preclinical abortion (β-hCG \u3e25 mIU/ml with no fetal cardiac activity) and clinical pregnancy (β-hCG \u3e25 mIU/ml with fetal cardiac activity on transvaginal scan). In addition, reproductive outcomes; implantation rate, clinical pregnancy rate and miscarriage rate among obese and non-obese PCOS and non-PCOS patients were compared.Results: Our results revealed 38.5% clinical pregnancy rate in non-PCOs females, 23.8% in non-obese PCOS females whereas 26.4% in obese PCOS. Preclinical abortions were found to be highest (31.5%) in non-obese PCOS females and were the lowest (26.2%) in non-PCOS females. In non-PCOS group and non-obese PCOS females 35.4% and 44.6%, respectively, failed to become pregnant.Conclusion: The success after ICSI in terms of number of clinical pregnancies was more in non-PCOS patients as compared to PCOS. Increase in body mass index reflected a negative impact on the reproductive outcome in PCOS patients

Use of follicular output rate to predict intracytoplasmic sperm injection outcome

Background: The measurement of follicular output rate (FORT) has been proposed as a good indicator for evaluating follicular response to the exogenous recombinant folliclestimulating hormone (rFSH). This places FORT as a promising qualitative marker for ovarian function. The objective of the study was to determine FORT as a predictor of oocyte competence, embryo quality and clinical pregnancy after intracytoplasmic sperm injection (ICSI).Materials and Methods: This prospective study was carried out on a group of infer- tile females (n=282) at Islamabad Clinic Serving Infertile Couples, Islamabad, Pakistan, from June 2010 till August 2013. Downregulated females were stimulated in injection gonadotropins and on ovulation induction day, pre-ovulatory follicle count (PFC) was determined using transvaginal ultrasound scan (TVUS), and FORT was determined as a ratio of PFC to antral follicle count (AFC)*100. Group I consisted of females with a negative pregnancy test, while group II had a positive pregnancy test that was confirmed with the appearance of fetal cardiac activity. Linear regression analyses of categorical variables of clinical pregnancy along with other independent variables, including FORT, were performed using SPSS version 15.0.Results: Pregnancy occurred in 101/282 women who were tested, recording a clinical pregnancy rate of about 35.8%. FORT values were higher in group II as compared to group I females (P=0.0001). In multiple regression analysis, 97.7, 87.1, 78.2, and 83.4% variations were explained based on the number of retrieved oocytes per patients, number of metaphase II oocytes retrieved, number of fertilized oocytes, and number of cleaved embryos, respectively, indicating FORT as an independent predictor.Conclusion: FORT is a predictor of oocyte competence in terms of a number of retrieved, mature and fertilized oocytes. It also gives information about the number of cleaved embryos and clinical pregnancy rate

Post-operative pain management modalities employed in clinical trials for adult patients in LMIC; a systematic review

Background: Unrelieved postoperative pain afflicts millions each year in low and middle income countries (LMIC). Despite substantial advances in the study of pain, this area remains neglected. Current systematic review was designed to ascertain the types of clinical trials conducted in LMIC on postoperative pain management modalities over the last decade.Methods: A comprehensive search was performed in June 2019 on PubMed, Cochrane Library, CINAHL Plus, and Web of Science databases to identify relevant trials on the management of postoperative pain in LMIC. Out of 1450 RCTs, 108 studies were reviewed for quality evidence using structured form of critical appraisal skill program. Total of 51 clinical trials were included after applying inclusion/exclusion criteria.Results: Results are charted according to the type of surgery. Eleven trials on laparoscopic cholecystectomy used multimodal analgesia including some form of regional analgesia. Different analgesic modalities were studied in 4 trials on thoracotomy, but none used multimodal approach. In 11 trials on laparotomy, multimodal analgesia was employed along with the studied modalities. In 2 trials on hysterectomy, preemptive pregabalin or gabapentin were used for reduction in rescue analgesia. In 13 trials on breast surgical procedures and 10 on orthopaedic surgery, multimodal analgesia was used with some form of regional analgesia.Conclusion: We found that over the past 10 years, clinical trials for postoperative pain modalities have evolved in LMIC according to the current postoperative pain management guidelines i.e. multi-modal approach with some form of regional analgesia. The current review shows that clinical trials were conducted using multimodal analgesia including but not limited to some form of regional analgesia for postoperative pain in LMIC however this research snapshot (of only three countries) may not exactly reflect the clinical practices in all 47 countries. Post Operative Pain Management Modalities Employed in Clinical Trials for Adult Patients in LMIC; A Systematic Review

The impact of immediate breast reconstruction on the time to delivery of adjuvant therapy: the iBRA-2 study

Background: Immediate breast reconstruction (IBR) is routinely offered to improve quality-of-life for women requiring mastectomy, but there are concerns that more complex surgery may delay adjuvant oncological treatments and compromise long-term outcomes. High-quality evidence is lacking. The iBRA-2 study aimed to investigate the impact of IBR on time to adjuvant therapy. Methods: Consecutive women undergoing mastectomy ± IBR for breast cancer July–December, 2016 were included. Patient demographics, operative, oncological and complication data were collected. Time from last definitive cancer surgery to first adjuvant treatment for patients undergoing mastectomy ± IBR were compared and risk factors associated with delays explored. Results: A total of 2540 patients were recruited from 76 centres; 1008 (39.7%) underwent IBR (implant-only [n = 675, 26.6%]; pedicled flaps [n = 105,4.1%] and free-flaps [n = 228, 8.9%]). Complications requiring re-admission or re-operation were significantly more common in patients undergoing IBR than those receiving mastectomy. Adjuvant chemotherapy or radiotherapy was required by 1235 (48.6%) patients. No clinically significant differences were seen in time to adjuvant therapy between patient groups but major complications irrespective of surgery received were significantly associated with treatment delays. Conclusions: IBR does not result in clinically significant delays to adjuvant therapy, but post-operative complications are associated with treatment delays. Strategies to minimise complications, including careful patient selection, are required to improve outcomes for patients

Effects of antibiotic resistance, drug target attainment, bacterial pathogenicity and virulence, and antibiotic access and affordability on outcomes in neonatal sepsis: an international microbiology and drug evaluation prospective substudy (BARNARDS)

Background Sepsis is a major contributor to neonatal mortality, particularly in low-income and middle-income countries (LMICs). WHO advocates ampicillin–gentamicin as first-line therapy for the management of neonatal sepsis. In the BARNARDS observational cohort study of neonatal sepsis and antimicrobial resistance in LMICs, common sepsis pathogens were characterised via whole genome sequencing (WGS) and antimicrobial resistance profiles. In this substudy of BARNARDS, we aimed to assess the use and efficacy of empirical antibiotic therapies commonly used in LMICs for neonatal sepsis. Methods In BARNARDS, consenting mother–neonates aged 0–60 days dyads were enrolled on delivery or neonatal presentation with suspected sepsis at 12 BARNARDS clinical sites in Bangladesh, Ethiopia, India, Pakistan, Nigeria, Rwanda, and South Africa. Stillborn babies were excluded from the study. Blood samples were collected from neonates presenting with clinical signs of sepsis, and WGS and minimum inhibitory concentrations for antibiotic treatment were determined for bacterial isolates from culture-confirmed sepsis. Neonatal outcome data were collected following enrolment until 60 days of life. Antibiotic usage and neonatal outcome data were assessed. Survival analyses were adjusted to take into account potential clinical confounding variables related to the birth and pathogen. Additionally, resistance profiles, pharmacokinetic–pharmacodynamic probability of target attainment, and frequency of resistance (ie, resistance defined by in-vitro growth of isolates when challenged by antibiotics) were assessed. Questionnaires on health structures and antibiotic costs evaluated accessibility and affordability. Findings Between Nov 12, 2015, and Feb 1, 2018, 36 285 neonates were enrolled into the main BARNARDS study, of whom 9874 had clinically diagnosed sepsis and 5749 had available antibiotic data. The four most commonly prescribed antibiotic combinations given to 4451 neonates (77·42%) of 5749 were ampicillin–gentamicin, ceftazidime–amikacin, piperacillin–tazobactam–amikacin, and amoxicillin clavulanate–amikacin. This dataset assessed 476 prescriptions for 442 neonates treated with one of these antibiotic combinations with WGS data (all BARNARDS countries were represented in this subset except India). Multiple pathogens were isolated, totalling 457 isolates. Reported mortality was lower for neonates treated with ceftazidime–amikacin than for neonates treated with ampicillin–gentamicin (hazard ratio [adjusted for clinical variables considered potential confounders to outcomes] 0·32, 95% CI 0·14–0·72; p=0·0060). Of 390 Gram-negative isolates, 379 (97·2%) were resistant to ampicillin and 274 (70·3%) were resistant to gentamicin. Susceptibility of Gram-negative isolates to at least one antibiotic in a treatment combination was noted in 111 (28·5%) to ampicillin–gentamicin; 286 (73·3%) to amoxicillin clavulanate–amikacin; 301 (77·2%) to ceftazidime–amikacin; and 312 (80·0%) to piperacillin–tazobactam–amikacin. A probability of target attainment of 80% or more was noted in 26 neonates (33·7% [SD 0·59]) of 78 with ampicillin–gentamicin; 15 (68·0% [3·84]) of 27 with amoxicillin clavulanate–amikacin; 93 (92·7% [0·24]) of 109 with ceftazidime–amikacin; and 70 (85·3% [0·47]) of 76 with piperacillin–tazobactam–amikacin. However, antibiotic and country effects could not be distinguished. Frequency of resistance was recorded most frequently with fosfomycin (in 78 isolates [68·4%] of 114), followed by colistin (55 isolates [57·3%] of 96), and gentamicin (62 isolates [53·0%] of 117). Sites in six of the seven countries (excluding South Africa) stated that the cost of antibiotics would influence treatment of neonatal sepsis

Postoperative pain management modalities used for adult patients in LMIC – A systematic review of randomized controlled trials

Background: Unrelieved postoperative pain afflicts millions each year in LMIC. Despite substantial advances in the study of pain, this area remains neglected. Anesthesia and related specialties have been reporting the enormity of the burden of pain and suffering in LMIC citing disproportionately limited resources, lack of regulations, and paucity of pain education as main reasons Current systematic review was designed to the ascertain the types of modalities studied over the last decade in the LMIC for possible use in the management of postoperative pain in adult patients.Methodology: A comprehensive search was performed in December 2018 on PubMed, Cochrane Library, CINAHL Plus, and Web of Science databases to identify relevant studies on the management of postoperative pain in LMIC. Out of 1450 RCTs, 108 studies were reviewed for quality evidence using structured form of critical appraisal skill program. After inclusion/exclusion criteria were ap[1]plied. 51 studies were included,Results: 11 trials on laparoscopic cholecystectomy used multimodal analgesia including some form of regional anesthesia. Different analgesic modalities were studied in four trials on thoracotomy but none used multimodal approach. In 11 trials on laparotomy, multimodal analgesia was employed along with the studied modalities. In two trials on hysterectomy, preemptive pregabalin or gabapentin were used for reduction in rescue analgesia. In 13 trials on breast surgical procedures and 10 on orthopedic surgery, multimodal analgesia was used with some form of regional analgesia.Conclusion: Postoperative pain is managed by multimodal approach following common surgical procedures in LMIC. Some form of regional analgesia is frequently used. Though the small snapshot reflects practices according to the current guidelines, these results should be interpreted cautiously as majority of studies are small and heterogeneous