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Abstract Sitagliptin is a dipeptidyl peptidase-4 (DPP IV, CD26) inhibitor indicated for treatment of Type II diabetes as a second line therapy after metformin. We report fifteen sitagliptin intolerant patients who developed anterior and posterior rhinorrhea, cough, dyspnea, and fatigue. Symptoms typically developed within 1 to 8 weeks of starting, and resolved within 1 week of stopping the drug. Peak expiratory flow rates increased 34% in 8 patients who stopped sitagliptin. Similar changes were found in 4 out of 5 persons who had confirmatory readministration. Chart review identified 17 patients who tolerated sitagliptin and had no symptomatic changes. The sitagliptin intolerant group had higher rates of clinically diagnosed allergic rhinitis (15/15 vs. 6/18; p = 0.00005), Fisher's Exact test) and angiotensin converting enzyme inhibitor - induced cough (6/13 vs. 1/18; p = 0.012). Nasal and inhaled glucocorticoids may control the underlying allergic inflammation and abrogate this new sitagliptin - induced pharmacological syndrome. Potential mucosal and central nervous system mechanisms include disruption of neuropeptides and/or cytokines that rely on DPP IV for activation or inactivation, and T cell dysfunction.

Background: Heavy menstrual bleeding (HMB) affects a significant number of women with bleeding disorders and has a negative impact on their quality of life., Objective: This retrospective study examined the management of patients with inherited bleeding disorders who used medical treatments, alone or in combination, for HMB., Methods: Chart review was performed on women attending the Women with Bleeding Disorders Clinic in Kingston, Ontario, between 2005 and 2017. Data collected included patient demographics, the reason for presentation and diagnosis, medical history, treatments, and patient satisfaction., Results: One hundred nine women were included in this cohort. Of these, only 74 (68%) were satisfied with medical management, and only 18 (17%) with first-line therapy. Treatments included combined contraceptives (oral pill, transdermal patch, and vaginal ring), progesterone-only pills, tranexamic acid, 52-mg levonorgestrel intrauterine system (LIUS), depomedroxyprogesterone acetate, and desmopressin, either alone or in combination. Satisfactory control of HMB occurred most often with the LIUS., Conclusion: In this cohort, managed in a tertiary care Women with Bleeding Disorders Clinic, only 68% of patients had successful control of HMB with medical treatment, and a minority were satisfied with first-line therapy. These data clearly highlight the need for additional research, including treatment approaches and novel therapies for this population., (© 2023 The Authors.)

Arbuscular mycorrhizal fungi (AMF) and herbivores are ubiquitous biotic agents affecting plant fitness. While individual effects of pairwise interactions have been well-studied, less is known about how species interactions above and belowground interact to influence phenotypic plasticity in plant functional traits, especially phytochemicals. We hypothesized that mycorrhizae would mitigate negative herbivore effects by enhancing plant physiology and reproductive traits. Furthermore, we expected genotypic variation would influence functional trait responses to these biotic agents. To test these hypotheses, we conducted a manipulative field-based experiment with three strawberry ( Fragaria x ananassa) genotypes to evaluate plant phenotypic plasticity in multiple functional traits. We used a fully-crossed factorial design in which plants from each genotype were exposed to mycorrhizal inoculation, herbivory, and the combined factors to examine effects on plant growth, reproduction, and floral volatile organic compounds (VOCs). Genotype and herbivory were key determinants of phenotypic variation, especially for plant physiology, biomass allocation, and floral volatiles. Mycorrhizal inoculation increased total leaf area, but only in plants that received no herbivory, and also enhanced flower and fruit numbers across genotypes and herbivory treatments. Total fruit biomass increased for one genotype, with up to 30-40% higher overall yield depending on herbivory. Herbivory altered floral volatile profiles and increased total terpenoid emissions. The effects of biotic treatments, however, were less important than the overall influence of genotype on floral volatile composition and emissions. This study demonstrates how genotypic variation affects plant phenotypic plasticity to herbivory and mycorrhizae, playing a key role in shaping physiological and phytochemical traits that directly and indirectly influence productivity., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Whyle, Trowbridge and Jamieson.)

The floral microbiome is of significant relevance to plant reproduction and crop productivity. While plant genotype is key to floral microbiome assembly, whether and how genotypic variation in floral traits and plant-level mutualistic and antagonistic interactions at the rhizosphere and phyllosphere influence the microbiome in the anthosphere remain little known. Using a factorial field experiment that manipulated biotic interactions belowground (mycorrhizae treatments) and aboveground (herbivory treatments) in three strawberry genotypes, we assessed how genotypic variation in flower abundance and size and plant-level biotic interactions influence the bidirectional relationships between floral volatile organic compounds (VOCs) and the floral microbiome using structural equation modeling. We found that plant genotype played a stronger role, overall, in shaping the floral microbiome than biotic interactions with mycorrhizae and herbivores. Genotypic variation in flower abundance and size influenced the emission of floral VOCs, especially terpenes (e.g. α- and β-pinene, ocimene isomers) and benzenoids (e.g. p-anisaldehyde, benzaldehyde), which in turn affected floral bacterial and fungal communities. While the effects of biotic interactions on floral traits including VOCs were weak, mycorrhizae treatments (mycorrhizae and herbivory + mycorrhizae) affected the fungal community composition in flowers. These findings improve our understanding of the mechanisms by which plant genotype influences floral microbiome assembly and provide the first evidence that biotic interactions in the rhizosphere and phyllosphere can influence the floral microbiome, and offer important insights into agricultural microbiomes., (© The Author(s) 2022. Published by Oxford University Press on behalf of Nanjing Agricultural University.)

Objective: Our study assessed the rate of new and recurrent Chlamydia trachomatis and Neisseria gonorrhoeae infections in the third trimester at an adolescent obstetrics clinic., Method: Between October 2016 and June 2020, routine third-trimester screening for C. trachomatis and N. gonorrhoeae was implemented according to new Canadian recommendations. Urine nucleic acid amplification was performed. Patient records were reviewed retrospectively, and demographic data; pregnancy and delivery characteristics; and information on screening at presentation to care, third-trimester screening (33-38 weeks), and other STI testing was recorded., Results: A total of 115 adolescents (mean age 17.90 ± 1.43 y) with 125 pregnancies presented for care. Twenty-three pregnancies were excluded (12 transferred out and 11 experienced a pregnancy loss). At presentation, screening was performed in 100 of 102 pregnancies: 64 of 100 at <13 weeks, 32 of 100 at 13-27 weeks, and 4 of 100 at 28-30 weeks. Nine tested positive for C. trachomatis and none tested positive for N. gonorrhoeae. In the third trimester, there were 3 positive C. trachomatis tests, but all were indicated: test of cure was due for 1 patient, 1 patient had a new sexual partner, and 1 patient presented with symptoms. The remaining 89 of 102 pregnancies were screened (with no other indication) and none were positive for C. trachomatis or N. gonorrhoeae. Ten patients could not be sampled (5 missed, 4 pre-term deliveries, and 1 non-compliant with testing)., Conclusion: No cases of C. trachomatis or N. gonorrhoeae infection were identified on third-trimester screening in our study. Adolescent obstetrics providers implementing Canadian screening guidelines may want to monitor their screening results to determine whether their yield warrants universal implementation., (Copyright © 2021. Published by Elsevier Inc.)

Climate warming can influence interactions between plants and associated organisms by altering levels of plant secondary metabolites. In contrast to studies of elevated temperature on aboveground phytochemistry, the consequences of warming on root chemistry have received little attention. Herein, we investigated the effects of elevated temperature, defoliation, and genotype on root biomass and phenolic compounds in trembling aspen (Populus tremuloides). We grew saplings of three aspen genotypes under ambient or elevated temperatures (+4-6 °C), and defoliated (by 75%) half of the trees in each treatment. After 4 months, we harvested roots and determined their condensed tannin and salicinoid (phenolic glycoside) concentrations. Defoliation reduced root biomass, with a slightly larger impact under elevated, relative to ambient, temperature. Elevated temperature decreased condensed tannin concentrations by 21-43% across the various treatment combinations. Warming alone did not alter salicinoid concentrations but eliminated a small negative impact of defoliation on those compounds. Graphical vector analysis suggests that effects of warming and defoliation on condensed tannins and salicinoids were predominantly due to reduced biosynthesis of these metabolites in roots, rather than to changes in root biomass. In general, genotypes did not differ in their responses to temperature or temperature by defoliation interactions. Collectively, our results suggest that future climate warming will alter root phytochemistry, and that effects will vary among different classes of secondary metabolites and be influenced by concurrent ecological interactions such as herbivory. Temperature- and herbivory-mediated changes in root chemistry have the potential to influence belowground trophic interactions and soil nutrient dynamics.

Perceptions of physical attractiveness vary across cultural groups, particularly for female body size and shape. It has been hypothesized that visual media propagates Western "thin ideals." However, because cross-cultural studies typically consider groups highly differentiated on a number of factors, identifying the causal factors has thus far been impossible. In the present research, we conducted "naturalistic" and controlled experiments to test the influence of media access on female body ideals in a remote region of Nicaragua by sampling from villages with and without regular TV access. We found that greater TV consumption remained a significant predictor of preferences for slimmer, curvier female figures after controlling for a range of other factors in an ethnically balanced sample of 299 individuals (150 female, aged 15-79) across 7 villages. Within-individual analyses in 1 village over 3 years also showed an association between increased TV consumption and preferences for slimmer figures among some participants. Finally, an experimental study in 2 low-media locations demonstrates that exposure to media images of fashion models can directly impact participants' body size ideals. We provide the first converging cross-sectional, longitudinal, and experimental evidence from field-based research, that media exposure can drive changes in perceptions of female attractiveness. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Wild bees are important pollinators in many ecosystems threatened by anthropogenic disturbance. Urban development can reduce and degrade natural habitat for bees and other pollinators. However, some researchers suggest that cities could also provide refuge for bees, given that agricultural intensification may pose a greater risk. In this study, we surveyed bee communities at 15 farms and gardens across an urban-rural gradient in southeastern Michigan, USA to evaluate the effect of urbanization on bees. We examined how floral resources, bee functional traits, temperature, farm size, and the spatial scale of analysis influence bee response to urbanization. We found that urbanization positively affected bee diversity and evenness but had no effect on total abundance or species richness. Additionally, urbanization altered bee community composition via differential effects on bee species and functional groups. More urbanized sites supported a greater number of exotic, above-ground nesting, and solitary bees, but fewer eusocial bees. Blooming plant species richness positively influenced bee species diversity and richness. Furthermore, the amount of available floral resources was positively associated with exotic and eusocial bee abundances. Across sites, nearly 70% of floral resources were provided by exotic plants, most of which are characterized as weedy but not invasive. Our study demonstrates that urbanization can benefit some bee species and negatively impact others. Notably, Bombus and Lasioglossum (Dialictus), were two important pollinator groups negatively affected by urbanization. Our study supports the idea that urban environments can provide valuable habitat for diverse bee communities, but demonstrates that some bees are vulnerable to urbanization. Finally, while our results indicate that increasing the abundance and richness of floral resources could partially compensate for negative effects of urbanization on bees, the effectiveness of such measures may be limited by other factors, such as urban warming., Competing Interests: The authors have declared that no competing interests exist.

A growing body of research indicates that cities can support diverse bee communities. However, urbanization may disproportionately benefit exotic bees, potentially to the detriment of native species. We examined the influence of urbanization on exotic and native bees using two datasets from Michigan, USA. We found that urbanization positively influenced exotic-but not native-bee abundance and richness, and that this association could not be explained by proximity to international ports of entry, prevalence of exotic flora or urban warming. We found a negative relationship between native and exotic bee abundance at sites with high total bee abundance, suggesting that exotic bees may negatively affect native bee populations. These effects were not driven by the numerically dominant exotic honeybee, but rather by other exotic bees. Our findings complicate the emerging paradigm of cities as key sites for pollinator conservation.

Background: Abdominal pain, secondary amenorrhea, and abnormal uterine bleeding are common gynecologic presentations in adolescence. Rarely this can be associated with an acquired hematometra. Hematometra is a condition of retained blood or clot within the uterus. High-dose progestogenic agents in this age group have been implicated in the accumulation of a hematometra without other explanation., Cases: We present 4 cases of hematometra after depomedroxyprogesterone acetate (DMPA) therapy in previously menstruating adolescents. All 4 presented with abdominal pelvic pain and/or persistent abnormal uterine bleeding, with the diagnosis confirmed via ultrasound. Suction dilation and curettage was required in each case., Summary and Conclusion: DMPA is a possible cause of hematometra and should be considered in anatomically normal young women experiencing pain or abnormal bleeding out of character for typical long-term DMPA use., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Natural and managed ecosystems are undergoing rapid environmental change due to a growing human population and associated increases in industrial and agricultural activity. Global environmental change directly and indirectly impacts insect herbivores and pollinators. In this review, we highlight recent research examining how environmental change factors affect plant chemistry and, in turn, ecological interactions among plants, herbivores, and pollinators. Recent studies reveal the complex nature of understanding global change effects on plant secondary metabolites and plant-insect interactions. Nonetheless, these studies indicate that phytochemistry mediates insect responses to environmental change. Future research on the chemical ecology of plant-insect interactions will provide critical insight into the ecological effects of climate change and other anthropogenic disturbances. We recommend greater attention to investigations examining interactive effects of multiple environmental change factors in addition to chemically mediated plant-pollinator interactions, given limited research in these areas., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Television consumption influences perceptions of attractive female body size. However, cross-cultural research examining media influence on body ideals is typically confounded by differences in the availability of reliable and diverse foodstuffs. 112 participants were recruited from 3 Nicaraguan villages that differed in television consumption and nutritional status, such that the contribution of both factors could be revealed. Participants completed a female figure preference task, reported their television consumption, and responded to several measures assessing nutritional status. Communities with higher television consumption and/or higher nutritional status preferred thinner female bodies than communities with lower television consumption and/or lower nutritional status. Bayesian mixed models estimated the plausible range of effects for television consumption, nutritional status, and other relevant variables on individual preferences. The model explained all meaningful differences between our low-nutrition villages, and television consumption, after sex, was the most likely of these predictors to contribute to variation in preferences (probability mass >95% when modelling only variables with zero-order associations with preferences, but only 90% when modelling all possible predictors). In contrast, we found no likely link with nutritional status. We thus found evidence that where media access and nutritional status are confounded, media is the more likely predictor of body ideals.

Internalization of a thin ideal has been posited as a key risk factor in the development of pathological eating attitudes. Cross-culturally, studies have found a preference for heavier bodies in populations with reduced access to visual media compared to Western populations. As yet, however, there has been little attempt to control for confounding variables in order to isolate the effects of media exposure from other cultural and ecological factors. Here, we examined preferences for female body size in relation to television consumption in Nicaraguan men and women, while controlling for the potential confounding effects of other aspects of Westernization and hunger. We included an urban sample, a sample from a village with established television access, and a sample from a nearby village with very limited television access. The highest BMI preferences were found in the village with least media access, while the lowest BMI preferences were found in the urban sample. Data from the rural sample with established television access were intermediate between the two. Amongst rural women in particular, greater television consumption was a stronger predictor of body weight preferences than acculturation, education, hunger, or income. We also found some evidence for television consumption increasing the likelihood of women seeking to lose weight, possibly via body shape preferences. Overall, these results strongly implicate television access in establishing risk factors for body image disturbances in populations newly gaining access to Western media., (© 2016 The British Psychological Society.)

Objective: New recommendations from the Ontario Cervical Cancer Screening Program indicate that initiation of screening should be delayed to age 21. However, there is sparse evidence pertaining to pregnant adolescents. Our objective was to determine whether early cervical cancer screening in pregnant adolescents confers an advantage over delayed screening in the prevention of cervical carcinoma., Methods: We conducted a retrospective cohort study of cervical cancer screening in all pregnant adolescents receiving antenatal care through an obstetrics clinic for adolescents between 2000 and 2010. Clinic attendees had an antenatal and/or postpartum Pap smear, with follow-up according to standard recommendations. Results were recorded together with information on regression, persistence, or progression of abnormal cytology, colposcopy referrals, and cervical biopsies. There is a single regional colposcopy clinic., Results: At least one Pap smear result was documented in 365 of the 388 patients. Of these 365 smears, 88 had abnormal cytology, 76 (86.4%) of which were reported as atypical cells of undetermined significance/low-grade squamous intraepithelial lesion, 11 (12.5%) high-grade squamous intraepithelial lesion (HSIL), and one atypical glandular cells (1.1%). Follow-up cytology was available for 78 patients. No patient lost to follow-up had subsequent referrals for colposcopic assessment in the region. Overall, cytologic abnormalities regressed in 75 (96.1%), persisted in two (2.6%), and progressed in one patient (1.3%). Twenty-three patients (of 365) required a total of 68 colposcopy visits and 17 biopsies, but ultimately only three loop electrosurgical excision procedures (LEEPs) and one laser vaporization were performed. Only one LEEP in a 20-year-old demonstrated HSIL., Conclusion: This population of pregnant adolescents had a high incidence of low-grade cervical abnormalities with a high rate of regression. Routinely screening these pregnant adolescents resulted in numerous repeat visits, repeat Pap smears, and colposcopy referrals, and led to patient anxiety and systemic costs. Not a single case of cervical cancer was prevented that would not otherwise have been identified by adherence to the new guidelines., (Copyright © 2016 Society of Obstetricians and Gynaecologists of Canada. Published by Elsevier Inc. All rights reserved.)

Introduction: Uterine perforation is an uncommon yet well-known complication of copper intrauterine devices and the levonorgestrel intrauterine system (IUS). While initial extrauterine placement at the time of insertion is felt to be the cause of perforation in most cases, some hypothesize that delayed transmural migration and subsequent perforation can occur with slightly malpositioned or even properly placed devices., Case: A 46-year-old female had a 52-mg levonorgestrel IUS inserted for menstrual management and contraception. We arranged a follow-up ultrasound as the uterus was enlarged on bimanual examination and the cavity sounded to 11cm. This ultrasound was completed 6days after insertion and reported the IUS to be in the "upper uterine cavity". Over time, transmural displacement and perforation of the horizontal arms of the device occurred. Computed tomography scans performed over 2years for nongynecologic indications document this gradual migration. A retrospective review of initial ultrasound images showed no evidence of uterine defect, embedment or perforation but the cavity length did appear to be less than 11cm., Conclusions: While initial extrauterine placement at the time of insertion is the most common mechanism of perforation, delayed transmural migration is another mechanism that can occur., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Study Objective: To create a family tree to chronicle the proliferation of our specialty through fellowships (formal and informal) within the pediatric and adolescent gynecology practice and among the membership of the North American Society for Pediatric and Adolescent Gynecology (NASPAG). This historical project was undertaken as a way to demonstrate NASPAG's rich sense of heritage and community. The tree is meant to be a dynamic project, a living document, changing and expanding as this field of medicine grows, and offers a form of institutional memory for NASPAG., Design, Setting, Participants, and Interventions: Questionnaires were sent out to all current NASPAG members via e-mail (and the list-serve) and were available at the 2014 NASPAG Annual Clinical and Research Meeting. Data from the questionnaires were recorded within GRAMPS 3.4.8, software used to create a family tree., Main Outcome Measures and Results: The result of the project was an elegant and intricate tree, containing 379 "family members" including physicians who specialize in pediatric and adolescent gynecology, adolescent medicine, reproductive endocrinology and infertility, and pediatric endocrinology., Conclusion: The family tree, which shows how one mentor might train multiple trainees and how past trainees later become mentors, highlights the value of physicians who take on supervisory and educational roles and the existence of comprehensive and inspirational training programs., (Copyright © 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Study Objective: In this study we aimed to collect and analyze CO levels as an indirect measure of smoke exposure in pregnant adolescents., Design, Setting, and Participants: Participants included pregnant adolescents who received antenatal care over 18 months (2012-2013) at the Multidisciplinary Teen Obstetrics Clinic at a tertiary-care hospital in Southeastern Ontario., Interventions: The CO breath test is a noninvasive method that is used to assess smoke exposure, in which nonsmokers have levels of 0-6 ppm, and levels of 7-10, 11-20 and more than 20 ppm are consistent with light, typical, and heavy smokers, respectively. Expired CO, smoking status, cigarette number, and home secondhand smoke exposure were documented at 3 clinic visits., Main Outcome Measures: To determine mean CO levels as a measure of smoke exposure and prevalence of secondhand smoke exposure., Results: The mean age of participants was 17.6 years. CO means (ppm) across 3 visits were 6.0, 5.9, and 4.8. Sixty-two percent of patients were self-reported nonsmokers, 38% were self-reported smokers (n = 93). CO means (standard error of the mean) were consistently different for nonsmokers vs smokers at visits 1 to 3, respectively: 2.9 (0.79) vs 9.7 (1.8); 3.0 (0.71) vs 12.9 (2.2), and 2.4 (0.71) vs 8.8 (1.5; P < .01, t test; n = 91). Of patient's highest CO (COmax), 62%, 9%, 15%, and 12% had levels of 6 or less, 7-10, 11-20, and greater than 20, respectively. Eighty-four percent of pregnant adolescents had home secondhand smoke exposure, which included 40% of nonsmokers and 100% of smokers (n = 57). Although most nonsmokers had a COmax of 6 or fewer ppm, 56% of smokers had COmax greater than 10 ppm (P < .05, χ(2))., Conclusion: Emphasis on smoking cessation is imperative in pregnant adolescents and should particularly target partners and families, because secondhand smoke exposure was very prevalent., (Copyright © 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Background: Galactosemia is an inborn error of metabolism resulting in premature ovarian insufficiency in 80-90% of females. There have been no reported cases of biochemical ovarian failure followed by normal menses., Case: A 12-year-old girl with galactosemia presented for gynecologic consultation. Her follicle-stimulating hormone (FSH) and estradiol levels were 52.9 U/L and less than 100 pmol/L, respectively. She started exogenous estrogen to stimulate puberty. At 16, she had spontaneous regular menstrual cycles. FSH and luteinizing hormone (LH) levels reflected normal ovarian function. Hormonal contraception was provided. One year later, she was found to be in ovarian failure (FSH 86.6 U/L, LH 33.3 U/L), and both estradiol and anti-Müllerian hormone were undetectable., Summary and Conclusions: This case documents spontaneous resumption of ovarian function after galactosemia-related ovarian failure. The use of FSH and LH is potentially limited in predicting ovarian function in this population., (Copyright © 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Abnormal menstruation in adolescent girls can cause psychological and physical strain from excess, unpredictable, painful, or even absent bleeding. Care providers who understand what is normal and what is concerning can educate and often reassure the young woman and her family. When there is an abnormal or concerning scenario, they can initiate investigations and/or treatment in an expedient fashion to limit psychosocial and/or physical morbidity. This article provides pediatricians, family doctors, nurse practitioners, and adult gynecologists with the knowledge and understanding of the common complaints, differential diagnoses, and treatment strategies., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Study Objective: This study sought to analyze the effect of strategically timed local preventive education on reducing teen conception rates during known seasonal peaks in March and April., Design: All teen conceptions (age ≤ 19) from March and April 2010, 2011, and 2012 were identified using medical records data. Teen conceptions occurring in January 2010, 2011, and 2012 were also identified to control for any new trends in the community., Setting: A city of 160,000 with 1 tertiary care centre., Participants: Pregnant adolescents (age ≤ 19)., Interventions: During the month of February 2012, preventive education and media awareness strategies were aimed at parents, teachers, and teens., Main Outcome Measures: Adolescent conceptions in March and April 2012., Results: Conception rates in teens ≤18 years old were significantly reduced in March and April 2012 compared to March and April 2010 and 2011 (RR = 0.53, 95% CI = 0.32 - 0.88, P = .0132). There was an increase in conceptions in March and April 2012 compared to 2010 and 2011 among 19-year-olds (RR = 1.57, 95% CI = 0.84-2.9, P = .1500). Effect modification revealed our ≤18-year-old group and our 19-year-old group were distinct groups with different risk estimates (P = .0075)., Conclusions: Educational sessions were poorly attended and contraception clinic volume was static. We propose increased parental supervision in response to media reminders as a possible explanation for the reduction in adolescent conceptions (≤18 years old) seen in March 2012., (Copyright © 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Climate change and insect outbreaks are key factors contributing to regional and global patterns of increased tree mortality. While links between these environmental stressors have been established, our understanding of the mechanisms by which elevated temperature may affect tree-insect interactions is limited. Using a forest warming mesocosm, we investigated the influence of elevated temperature on phytochemistry, tree resistance traits, and insect performance. Specifically, we examined warming effects on forest tent caterpillar (Malacosoma disstria) and host trees aspen (Populus tremuloides) and birch (Betula papyrifera). Trees were grown under one of three temperature treatments (ambient, +1.7 °C, +3.4 °C) in a multiyear open-air warming experiment. In the third and fourth years of warming (2011, 2012), we assessed foliar nutrients and defense chemistry. Elevated temperatures altered foliar nitrogen, carbohydrates, lignin, and condensed tannins, with differences in responses between species and years. In 2012, we performed bioassays using a common environment approach to evaluate plant-mediated indirect warming effects on larval performance. Warming resulted in decreased food conversion efficiency and increased consumption, ultimately with minimal effect on larval development and biomass. These changes suggest that insects exhibited compensatory feeding due to reduced host quality. Within the context of observed phytochemical variation, primary metabolites were stronger predictors of insect performance than secondary metabolites. Between-year differences in phytochemical shifts corresponded with substantially different weather conditions during these two years. By sampling across years within an ecologically realistic and environmentally open setting, our study demonstrates that plant and insect responses to warming can be temporally variable and context dependent. Results indicate that elevated temperatures can alter phytochemistry, tree resistance traits, and herbivore feeding, but that annual weather variability may modulate warming effects leading to uncertain consequences for plant-insect interactions with projected climate change., (© 2015 John Wiley & Sons Ltd.)

As the world's climate warms, the phenologies of interacting organisms in seasonally cold environments may advance at differing rates, leading to alterations in phenological synchrony that can have important ecological consequences. For temperate and boreal species, the timing of early spring development plays a key role in plant-herbivore interactions and can influence insect performance, outbreak dynamics, and plant damage. We used a field-based, meso-scale free-air forest warming experiment (B4WarmED) to examine the effects of elevated temperature on the phenology and performance of forest tent caterpillar (Malacosoma disstria) in relation to the phenology of two host trees, aspen (Populus tremuloides) and birch (Betula papyrifera). Results of our 2-year study demonstrated that spring phenology advanced for both insects and trees, with experimentally manipulated increases in temperature of 1.7 and 3.4 °C. However, tree phenology advanced more than insect phenology, resulting in altered phenological synchrony. Specifically, we observed a decrease in the time interval between herbivore egg hatch and budbreak of aspen in both years and birch in one year. Moreover, warming decreased larval development time from egg hatch to pupation, but did not affect pupal mass. Larvae developed more quickly on aspen than birch, but pupal mass was not affected by host species. Our study reveals that warming-induced phenological shifts can alter the timing of ecological interactions across trophic levels. These findings illustrate one mechanism by which climate warming could mediate insect herbivore outbreaks, and also highlights the importance of climate change effects on trophic interactions.

Pelvic inflammatory disease (PID) is an infection of the upper genital tract that is often caused by an ascending sexually transmitted infection. The complications of PID include pyosalpinx and tubo-ovarian abscess, infertility or ectopic pregnancy, and chronic pelvic pain of varying degrees. These sequelae underscore the importance of prompt diagnosis. We present 2 cases of PID in young women who denied any history of sexual activity or sexual abuse. Both cases were brought to the operating room with suspected appendicitis; however, laparoscopic evaluation revealed purulent fluid surrounding the pelvic organs. The literature is scant with respect to PID in the virginal patient. It is important to keep pelvic infection in the differential diagnosis of virginal patients who present with clinical symptoms of an acute abdomen., (Copyright © 2014 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

The levonorgestrel-releasing intrauterine system (LNG-IUS) is indicated for the management of menorrhagia and for contraception. The LNG-IUS is effective at reducing menstrual bleeding and improving haemoglobin among women with bleeding disorders. Expulsion rates for the LNG-IUS among normal women are reported to be approximately 5-10%. The aim of this study was to examine the malposition and expulsion rates of the LNG-IUS among women with inherited bleeding disorders. We conducted a retrospective study of women with an inherited bleeding disorder in Kingston, Canada treated with an LNG-IUS between May 2005 and June 2012. The primary outcome was a combined endpoint of expulsion and/or malposition. Predetermined secondary outcomes were patient satisfaction and changes in haemoglobin and ferritin levels. The median age of the women at the time of LNG-IUS insertion was 31 years (range 18-43, mean 32.1 years). The most common diagnosis was type 1 VWD (12/20, 60%). There were three LNG-IUS expulsions and two episodes of device malposition resulting in removal [5/20 (25.0%), 95% CI 11.2-46.9%]. An additional five women had their device removed prematurely. The overall proportion of devices resulting in discontinuation in this population was 10/20 (50.0%, 95% CI 29.9-70.1%). In this retrospective study, a significant proportion of women with an inherited bleeding disorder had an LGN-IUS removed due to poor patient satisfaction, malposition, or expulsion. Further studies into the causes of higher complication rates and interventions such as premedication or prolonged treatment with antifibrinolytic agents targeted at improving outcomes in this population are required., (© 2013 John Wiley & Sons Ltd.)

Global environmental change alters the supply of multiple limiting resources that regulate plant primary and secondary metabolism. Through modifications in resource availability, acquisition, and allocation, global change is likely to influence plant chemical defenses, and consequently species interactions that are mediated by these compounds. While many studies focus on individual global change factors, simultaneous changes in abiotic factors may interact to influence plant allelochemicals. In this study, we examined the individual and interactive effects of nitrogen enrichment and altered precipitation patterns on chemical defense compounds (iridoid glycosides) of an invasive plant, Linaria dalmatica. Plants were grown from seed in native mixed-grass prairie for 2 years. Nitrogen and water treatments were applied in each growing season over this period. Results indicate that soil water and nitrogen availability interact to shape plant chemical defense concentrations in L. dalmatica. Nitrogen addition decreased iridoid glycoside concentrations by approximately 25% under reduced water availability, increased concentrations by 37% in ambient water plots, and had no effect on these chemical defenses for plants growing under augmented water supply. Thus, results show differing patterns of allelochemical response to nitrogen enrichment, with respect to both the magnitude and direction of change, depending on water availability. Our study demonstrates the importance of examining multiple environmental factors in order to predict potential changes in plant chemical defenses with climate change.

Use of orally administered flavored midazolam elixir in the office setting has been previously described as an alternative to general anesthetic for manual separation of severe or persistent labial adhesions. We share the technique of using atomized intranasal midazolam for sedation (and amnesia) that has quicker onset, shorter duration, and well described safety and patient tolerance. This technique eliminates the problems associated with a child who refuses to swallow the elixir., (Copyright © 2013 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Premise of the Study: Human nitrogen (N) inputs to terrestrial ecosystems have greatly increased in recent years and may have important consequences for plant growth, reproduction, and defense. Although numerous studies have investigated the effects of nitrogen addition on plants, few have examined both above- and belowground responses within a range of predicted increase and apart from concomitant increases in other nutrients. •, Methods: We conducted a greenhouse experiment to study the consequences of increased nitrogen inputs, such as those from atmospheric N deposition, on plant performance, chemical defenses, and allocation tradeoffs for an invasive species, Linaria dalmatica. This plant produces iridoid glycosides, which are a group of terpenoid compounds. •, Key Results: Soil nitrogen enrichment increased growth, reproduction, and whole-plant iridoid glycosides while decreasing some costs of defense. Interestingly, nitrogen addition had varying effects on defense allocation to above- and belowground tissues. Specifically, there was no change in iridoid glycoside concentrations of shoots, whereas concentrations decreased in flowers by ~35% and increased in roots by >400%. •, Conclusions: Observed increases in plant performance and chemical defenses may have implications for the invasion potential of L. dalmatica. Moreover, our results highlight the importance of evaluating both above- and belowground plant defenses. In particular, findings presented here indicate that research focused on leaf-level defenses may not detect key allelochemical responses, including changes in plant resistance traits that could affect consumers (e.g., herbivores and pathogens) that specialize on different plant tissues as well as plant fitness and invasion success.

Background: Many techniques have been used to create a neovagina in patients with vaginal agenesis, and several surgical procedures involve the use of a graft. Grafting techniques are associated with intraoperative and postoperative morbidity and complications, at both the donor and the recipient site., Case: A 17-year-old patient with Mayer-Rokitansky-Kuster-Hauser syndrome complicated by unilateral pelvic kidney underwent successful vaginoplasty without the use of a graft, followed by insertion of a vaginal stent for 12 weeks. She had a functional, well-healed, and fully epithelialized neovagina by 6.5 months postoperatively., Conclusion: Patients undergoing surgical vaginoplasty may benefit from this simple surgical technique, thereby avoiding the morbidity associated with the alternative grafting techniques commonly used in practice., (Copyright © 2012. Published by Elsevier Inc.)

Study Objective: The objectives of this study were to determine if a seasonal trend exists in adolescent pregnancies and to compare the teen conception rate per month to an adult population., Setting: The study was conducted in a tertiary care Canadian hospital that has a one-site model of care., Design: A retrospective chart review of all adolescent pregnancies over a 5-year period (N = 838) was undertaken. From the 13,554 adult pregnancies over the same time period, a random sample of 838 pregnancies was chosen for similar chart review. A chi-square test was used to compare the proportion of pregnancies conceived in each calendar month between the two groups., Participants: Pregnancies ending in spontaneous abortions, elective terminations, ectopic pregnancies, as well as obstetrical deliveries, were included., Results: There was a significantly different monthly trend seen in adolescent pregnancy conceptions when compared with the adult group (χ² = 24.38, df = 11, P = 0.0112). The adolescent group was observed to have a unique peak in the number of pregnancies conceived in March (10.5% of pregnancies conceived compared to 7.3% in adults). In addition, 8.5% of conceptions in adolescents occurred in December compared to 10.4% in adults., Conclusions: There are several plausible explanations for the modest but real differences identified in this study including trends in fecundity/fertility or social/school events that lead to increased sexual activity. Peaks in conception indicate times when a greater need for health care services exists, and when preventive education can be most effective., (Copyright © 2011 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Study Objective: The objective of this study was to report user statistics of an online contraception selection tool over a 6-month period, comparing preferences and characteristics of adolescents to those of adults., Setting: Choosing Wisely, available on the website www.SexualityandU.ca, is an interactive program that helps women select an ideal birth control method., Design: Answers to the online questionnaire were logged for a 6-month period. Answers of adolescent users were retrospectively reviewed for responses to questions regarding personal preferences and compared with those of adults., Participants: Participants of the study included users who self-identified as first-time users of Choosing Wisely., Results: 3178 adolescents (age ≤19) and 4206 adults self-identified as new users and completed the software module. Adolescents less commonly reported weighing over 198 pounds or to be smokers. 61% of adolescents would prefer to avoid menses (vs 52% of adults) and 83% of adolescent would find a pregnancy devastating (vs 64% of adults). 1720 (54%) of the adolescents had menstrual complaints; of these 500 (29%) did not believe they could reliably take a pill daily. The majority of both adolescents (73%) and adults (71%) claimed to be willing to use a contraceptive method that required interruption of intercourse., Conclusions: Choosing Wisely is attracting large numbers of teens and adults, whose responses provide insight into the characteristics of those seeking contraception. Our data corroborate the need for contraceptive options such as combined contraceptives that do not require daily pill-taking and contraceptives that offer menstrual management. However, the magnitude of these statistically significant differences was not always as impressive clinically., (Copyright © 2011 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Ambiguous genitalia is a significant example of a disorder of sexual development, in which the external genitalia do not have the typical appearance of either sex. Although the birth of a child with ambiguous genitalia is rare, the emergent nature of the issue demands that healthcare providers have at least a familiarity with the underlying etiologies, the issues, and the initial approach to diagnosis and management. With numerous etiologies, potential difficulties with reaching a diagnosis, and many challenges with immediate and long-term care, the topic of ambiguous genitalia can be daunting. We provide a review of basic embryology, as well as a classification system for understanding the various etiological causes of ambiguous genitalia. The important clinical aspects of diagnosis and management are also highlighted, and a teaching tool has been included to help the reader (or their learners) to solidify information presented. Our overall goal is to provide practical information on ambiguous genitalia and allow the clinician to apply this information to clinically relevant scenarios., (Copyright © 2011 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Background: Choosing Wisely, a user-friendly and interactive application developed and tested at Queen's University, is a self-administered computer-based questionnaire that aims to assist women, their partners, and their health care providers in deciding among contraceptive options. The application asks specific, direct questions regarding a patient's preferences, health, and lifestyle, and it then generates three lists: (1) indicated contraceptive methods, (2) options that may be suitable, and (3) contraindicated methods., Objective: To report statistics on the users of Choosing Wisely in the first 13 months since the launch of the program on the award-winning SOGC website Sexualityandu.ca in June, 2007., Methods: At the end of the program module, each user's answers were logged anonymously in a Microsoft Excel spreadsheet along with the time and date of completion. Descriptive statistics were generated in SPSS version 16.0., Results: Between June 21, 2007, and July 25, 2008, 9775 users completed the Choosing Wisely program. Of these users, 8942 (91.5%) were female, and 8745 (89.5%) were under 35. At least one concern regarding contraceptive options was reported by 7359 users (75.3%), and the most common of these was weight gain, selected by 4806 (65.3%)., Conclusion: Choosing Wisely has attracted an average of 24 users per day seeking more information on birth control methods. The responses gathered from the program will likely allow for both a better understanding of the characteristics of women who desire birth control and refinement of the program, with the aim of better serving those who are seeking contraceptive advice.

Study Objectives: To determine the lengths of the first and second stages of labor in a group of Canadian adolescents; to compare this timeline to the estimates from a general population, and to a heterogeneous group of adolescents from a previous study., Design: Retrospective chart review., Setting: Kingston General Hospital, Kingston, Ontario, Canada., Participants: This study included women 19 years old and under at the time of delivery, having had spontaneous labor and a term singleton cephalic vaginal delivery between 2000 and 2005., Main Outcome Measures: The primary outcome is the length of the first and second stages of labor. Impact of epidural use will be determined., Results: In adolescents undergoing spontaneous labor at term (n = 177), the median duration of the first stage was 6.8 and 3.2 hours for nulliparous and multiparous teens respectively, compared to 10.0 and 5.9 hours in a mostly adult population. The duration of the second stage, in term spontaneous vaginal deliveries, was 54 minutes for nulliparous and 10 minutes for multiparous adolescents, similar to the teens in Greenberg's 2007 study. Comparatively, median lengths of second stage for the general population were 92 minutes and 20 minutes for nulliparous and multiparous women respectively. Epidural analgesia had a significant influence on lengthening the second stage in adolescents, however second stages in teens were still shorter, when controlling for regional analgesia, than in a general population., Conclusions: Adolescents do have shorter both first and second stages when compared to a general group. These differences demonstrate the importance of determining a distinct timeline for evaluating the course of labor in teens., (Copyright 2010 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

The early phases of biological invasions are poorly understood. In particular, during the introduction, establishment, and possible lag phases, it is unclear to what extent evolution must take place for an introduced species to transition from established to expanding. In this study, we highlight three disparate data sources that can provide insights into evolutionary processes associated with invasion success: biological control organisms, horticultural introductions, and natural history collections. All three data sources potentially provide introduction dates, information about source populations, and genetic and morphological samples at different time points along the invasion trajectory that can be used to investigate preadaptation and evolution during the invasion process, including immediately after introduction and before invasive expansion. For all three data sources, we explore where the data are held, their quality, and their accessibility. We argue that these sources could find widespread use with a few additional pieces of data, such as voucher specimens collected at certain critical time points during biocontrol agent quarantine, rearing, and release and also for horticultural imports, neither of which are currently done consistently. In addition, public access to collected information must become available on centralized databases to increase its utility in ecological and evolutionary research.

Invasive plant species can have significant ecological and economic impacts. Although numerous hypotheses highlight the importance of the chemical defenses of invasive plant species, the chemical ecology of many invasive plants has not yet been investigated. In this study, we provide the first quantitative investigation of variation in iridoid glycoside concentrations of the invasive plant Dalmatian toadflax (Linaria dalmatica). We examined variation in chemical defenses at three levels: (1) variation within and among populations; (2) variation due to phenology and/or seasonal differences; and (3) variation among plant parts (leaves, flowers, and stems). Further, we examined two biological control agents introduced to control L. dalmatica for the ability to sequester iridoid glycosides from this invasive plant. Results indicate that L. dalmatica plants can contain high concentrations of iridoid glycosides (up to 17.4% dry weight of leaves; mean = 6.28 ± 0.5 SE). We found significant variation in iridoid glycoside concentrations both within and among plant populations, over the course of the growing season, and among plant parts. We also found that one biological control agent, Calophasia lunula (Lepidoptera: Noctuidae), was capable of sequestering antirrhinoside, an iridoid glycoside found in L. dalmatica, at levels ranging from 2.7 to 7.5% dry weight. A second biological control agent, Mecinus janthinus (Coleoptera: Curculionidae), a stem-mining weevil, did not sequester iridoid glycosides. The demonstrated variation in L. dalmatica chemical defenses may have implications for understanding variation in the degree of invasiveness of different populations as well as variation in the efficacy of biological control efforts.

Vulvovaginal complaints in the prepubertal child are a common reason for referral to the health care provider. The Cochrane Library and Medline databases were searched for articles published in English from 1980 to December 2004 relating to vulvovaginal conditions in girls. The following search terms were used: vulvovaginitis, prepubertal, pediatric, lichen sclerosis, labial fusion, labial adhesion, genital ulcers, urethral prolapse, psoriasis, and straddle injuries. The objectives of this article are to review the normal vulvovaginal anatomy, describe how to perform an age-appropriate examination, and discuss common vulvovaginal disorders and their management in young girls.

Although dysmenorrhea, pelvic mass or pain, genital irritation, and amenorrhea are relatively common complaints, the astute clinician needs a broad differential diagnosis to avoid missing uncommon underlying etiologies such as Müllerian anomalies and cryptomenorrhea, ovarian teratomas and torsion, labial hypertrophy, vaginal foreign bodies, dermopathies, genital ulcers, imperforate hymen, and the absent vagina. This article discusses and illustrates uncommon pediatric and adolescent gynecologic conditions that present with these common complaints.

Objective: To characterize the obstetric outcome and prevalence of anemia in primiparous adolescents and compare them with those in older primiparas., Methods: We conducted a retrospective chart review of 207 adolescents (or20 years old) whose prenatal care was provided by a single obstetrician in Kingston, Ontario, and who had a live singleton birth at >or24 weeks gestation between 1996 and 2004., Results: The mean age of the adolescents (T) was 17.5 years and of the adults (A) 27.3 years. More than 95% of the women were Caucasian. Mean gestational age at delivery was similar in the two groups (T 39.4 weeks, A 39.6 weeks, P = 0.25). Adolescents were more likely to have a preterm delivery (T 12.6%, A 7.5%, P = 0.038), although smoking rather than young maternal age was an independent risk factor for preterm delivery (odds ratio [OR] 3.2; 95% confidence intervals [CI] 1.47.5). A significantly lower proportion of adolescents delivered by Caesarean section (CS) (T 12.1%, A 27.7%, P < 0.001). Older maternal age, higher pre-pregnancy BMI, increased weight gain during pregnancy, and pre-delivery anemia were all independent risk factors for CS. Smoking was the most influential factor in predicting infant birth weight. Adolescents had significantly more low birth weight infants (< 2500 g) than adults (T 10.1% vs. A 4.3%, P = 0.008). Gestational age rather than young maternal age was the most significant risk factor for low birth weight (OR 3.3; 95% CI 1.95.7). After controlling for smoking status, adolescents were 2.5 times more likely than adults to be anemic at 26 to 35 weeks gestation and pre-delivery., Conclusion: Our results suggest that primiparous adolescents have significantly different obstetric outcomes from primiparous adults. Smoking and anemia are significant risk factors for poor obstetric outcomes and are potentially modifiable.

Study Objective: The purpose of this study was to report on our experience with the intrauterine contraceptive device (IUCD) in a group of properly counseled adolescents and to determine whether traditional hesitation with use in this population should be reconsidered., Design: Patients who had an IUCD inserted between April 1999 and March 2003 were identified using medical records and chart review., Setting: A single Canadian University teaching hospital supervised by a single gynecologist., Participants: Twenty-eight patients, 21 years of age and under, were identified. Twenty agreed to participate in the study., Interventions: Patients were contacted by mail to inform them of the study and subsequently interviewed using a 10-minute structured phone interview that contained seven primary questions with additional follow-up questions., Main Outcome Measures: Duration of use, reasons for removal, side effects experienced, satisfaction with use, prior contraception., Result: The average age at insertion was 18.7 years, the average time of use was 19.6 months and the average number of pregnancies prior to insertion was 1.4. Seven patients (35%) had discontinued use of their IUCD prior to the interview, with an average of 13.4 months between the time of insertion and removal. The most common reason for removal was increased bleeding. The most common side effect was increased cramping. Eighty-five percent (17/20) of users were either somewhat satisfied, satisfied or very satisfied with the IUCD., Conclusions: Following pre-insertion screening for STI-related cervicitis and with consistent follow-up following insertion, IUCDs are well-tolerated by properly selected and counseled adolescents who require an easy and effective long-term method of birth control.

This article describes both barrier and spermicide methods of contraception including the male and female condom, diaphragm, contraceptive sponge, Lea Shield, cervical cap and multiple spermicide options. Their efficacy, differences and proper use are discussed with an emphasis on the adolescent user.

Purpose of Review: Endometriosis can exist in the adolescent female. It can be a very disruptive disease and cause significant dysfunction at a time in life when self-esteem, school attendance, and school performance are critical to achievement of life goals. Approaches to diagnosis and management in the recent literature are reviewed, focusing on those that apply directly to the adolescent or indirectly, by extrapolation from work done in the adult population. Practical strategies for adolescent patient care are presented., Recent Findings: Recent research has focused on the efficacy of current treatment modalities and management of potential adverse side effects. Possible etiologies of endometriosis have been proposed, and therapies directed at those causes are being explored. Methods of diagnosis, both invasive and noninvasive, have been studied in order to determine the most effective way of diagnosing the disease., Summary: A better understanding of the etiology of endometriosis would probably assist in determining the most suitable treatment strategies. Future work in adolescent endometriosis should focus on developing safe, minimally invasive, yet definitive options for diagnosis and treatment.

Unilateral ovarian agenesis (UOA) and fallopian descent problems are very rare congenital defects. We present an unusual case of UOA associated with fallopian-tube maldescent discovered incidentally during a laparotomy in a female infant for a persistent heterogeneous right ovarian cyst refractory to needle aspiration. A necrotic, hemorrhagic paratubal cyst was found associated with a normal right adnexa. The left ovary was absent and a rudimentary left fallopian tube was found tightly stretched over the sigmoid colon to the left retroperitoneum. This previously unreported constellation of anomalies may carry significant potential risks for bowel obstruction and later fertility.

A case is presented in which an unusual, phallic-shaped perineal lipoma raised the question of ambiguous genitalia following the delivery of an otherwise healthy female infant. The management of the case is described, and the critical features of the physical examination that contradicted that diagnosis are highlighted.

Background: Adnexal torsion is a well-recognized cause of acute pelvic pain. Isolated tubal torsion with ovarian sparing has certainly been documented, but is uncommon. Although risk factors for the latter include a menstrual period, menarche in particular is not known to predispose a patient to this event. Severe unilateral pelvic pain with first menses is more likely to herald a congenital mullerian anomaly and cryptomenorrhea, particularly when accompanied by a pelvic mass. We present a case of tubal torsion where a coincidental, yet misleading temporal relation to menarche led to a delay in laparoscopy and ultimate diagnosis.Case: KG, an eleven-year-old female, experienced severe right-sided dysmenorrhea with her first and second menses in August and September 1999 respectively. Between episodes, pain, although still present, was more tolerable and the patient never required hospitalization. Ultrasound revealed a lobulated inhomogeneous mass posterior to the uterus and extending from one normal ovary to the other (Figures). MRI further described the mass as pseudoencapsulated with inhomogeneous areas of high attenuation on T1 and T2 images (Figures). Findings were consistent with an endometrioma, but admittedly could have represented a hemorrhagic cystic mass. No definite mullerian anomaly was seen to explain advanced endometriosis, but two focal areas within the endometrial canal raised the possibility of a uterine septum. Examination of the patient (one week after presentation) was not very helpful although she was pubertal, did have a hymenal septum and was mildly tender on bimanual examination in the Pouch of Douglas. The patient had been started on continuous oral contraceptives while undergoing investigations. Pain only recurred during an episode of break-through bleeding. Ultimately she came to laparoscopy and hysteroscopy where chronic right tubal torsion and necrosis was identified with an inflammatory/hemorrhagic reaction in the pelvis (Photos). There were no identifiable fimbria of the right tube which was densely adherent distally to perirectal fat (Photo). No obvious precipitant was found. Laparoscopic lysis of adhesions and right distal salpingectomy was performed (Photo). Her uterine cavity was in fact normal (Photo)Conclusion: Whether or not this patient's right tube was originally normal will never be known. Congenital abnormalities of fallopian tubes do occur and can predispose to torsion. Nonetheless, adnexal torsion must always be kept in mind whenever a woman presents with unilateral pelvic pain. Early diagnosis is paramount in children and women of reproductive age in order to improve the likelihood of adnexal salvage and future fertility. A "gold-standard" radiological investigative tool continues to elude us. Laparoscopy, albeit more invasive, remains an invaluable procedure in this context with relatively low morbidity as compared to the consequences of delayed diagnosis.