[Congenital hepatic fibrosis in pregnancy]. / Su un caso di fibrosi epatica congenita in gravidanza.

The purpose of this study was to analyse the course of pregnancy of a 20-year-old woman suffering from congenital hepatic fibrosis (CHF), a genetic disease with recessive autosomic transmission, attributed to the group of hepato-nephro-pancreatic fibropolycystic familial diseases. This was the only time such a case had ever been encountered in a pregnancy in the history of Turin University's Obstetrics and Gynaecological Clinic. The case of a 20-year-old woman is considered. She was admitted to our observation at the Obstetrics and Gynaecological Department of Faculty "B" of the University of Turin, suffering from CHF, a primigravid in the eighth week of gestation. Haematochemical tests carried out on the patient showed a platelet deficiency without evident changes in liver and renal function. Objective examination revealed a slight hepatosplenomegaly confirmed by abdominal echotomography. The haematochemical examinations subsequently carried out confirmed thrombocytopenia due to hepatosplenic hyperhaemocataresis. In agreement with the will of the patient and her family, and after having heard the opinion of our hospital's anaesthetists and internists, a conservative approach was decided on and close monitoring of maternal and foetal conditions was planned, with hospitalisations scheduled for every fortnight. Together with the internists and anaesthetists, it was decided to allow the pregnancy to proceed as far as foetal maturity but not to term, to avoid problems relating to the excessive increase in uterine volume which would have led to pressure on the portal tree and so favoured haemorrhaging due to rupture of the oesophageal varices. Caesarean delivery was planned for the 37th week of gestation. The birth went according to plan and the foetus was a live, vital male with Apgar index of 9/9. The placenta presented normal characteristics and a weight of 590 g. No haemorrhagic complications were observed either in the course of surgery or in the postoperative phase, notwithstanding the preoperative finding of a platelet count of 64,000 platelets/ mm3. Although in our case neither the pregnancy nor the delivery constituted a serious danger for the life of the mother, possible obstetric complications are among the most serious encountered in obstetric pathology and can lead both to maternal death and to the intrauterine death of the foetus. For these reasons we believe it essential to provide correct, clear and adequate information about the risks involved for patients suffering from congenital hepatic fibrosis, especially if they are associated with renal polycystic disease, and who are admitted to our wards with the desire to programme a pregnancy.

[Therapy for cervical intraepithelial neoplasia and fertility]. / Terapia delle lesioni preinvasive del collo dell'utero e fertilità

BACKGROUND: We reviewed the case records of patients of childbearing age treated with various types of surgical techniques for cervical intraepithelial neoplasia (CIN) to determine the impact of surgical treatment on their fertility. METHODS: Between 1983 and 1997 a total of 486 women with CIN received surgical treatment at out unit. Laser vaporization was used in 196 cases, cold-knife conization in 163 and REP in 127. The outcome of the various treatments was then compared. RESULTS: Independent of the surgical technique used, the percentage of pregnancies achieved after surgery was high: 93.33 and 96.66% of patients treated with laser vaporization and REP, respectively, and 87.69% of those who received cold-knife conization. The differences did not reach statistical significance nor were significant differences observed in the number of abortions or in the method of birth delivery (spontaneous, Cesarean section). However, a higher percentage of premature births was noted among women who received cold-knife conization (31.57%), which was statistically significant in the comparison among the three groups. CONCLUSIONS: The results from our study indicated which techniques for the treatment of CIN may be preferable. Compared with the other two techniques, cold-knife conization bears higher costs (hospitalization, general anesthesia) and has been superceded by laser vaporization and REP as evaluated in this series. When cold-knife conization must be used, cerclage of the cervix uteri should be performed in the event of future pregnancy. In contrast, laser vaporization and REP can be performed in an outpatient setting with local anesthesia. These techniques, because they are conservative, afford the advantages of complete lesion removal and maintenance of reproductive capability. Another important consideration is that REP is less costly and allows histological examination of the surgical specimen.

Ochratoxin A determination in ham by immunoaffinity clean-up and a quick fluorometric method.

A simple and rapid method for the determination of ochratoxin A (OA) in ham was developed using a basic methanolic extraction, immunoaffinity column clean-up and a fluorometric determination of the toxin contamination levels. A mean recovery of OA from ham samples spiked at levels from 0.7 to 9.7 microg kg(-1) was 83 +/- 6% using the fluorometric method, with a detection limit of 0.7 microg kg(-1). Recovery data were compared statistically with those obtained using reversed-phase high-performance liquid chromatography with acetonitrile-water-acetic acid (99:99:2) as mobile phase and fluorescence detection, commonly used for OA determination in food. A good correlation between the two analytical techniques was obtained. Both methods were successfully applied to 42 ham samples, 21 in the middle of the ripening period (after 6 months from the process beginning) and the other 21 at the end of the maturation, after 12 months. Twenty-seven samples (64%) showed an OA contamination level <1.0 microg kg(-1), the Italian Ministry of Health guideline. The maximum contamination level found was 2.3 microg kg(-1). A good agreement (R(2) = 0.980) between HPLC and fluorometer analysis on naturally contaminated samples was obtained.

[Antiestrogen therapy in the treatment of breast neoplasms]. / La terapia antiestrogenica nel trattamento del carcinoma della mammella.

During recent years the development of hormone therapy for the treatment breast neoplasms has seen, in addition to classic aspecific antiestrogens (AE) like tamoxifen (TAM) and to a lesser extent toremifen, a major development of new molecules divided into two groups: the first is the so-called selective estrogen receptor modulators (SERMs), the most important of which is Raloxifen, which mediate estrogen-agonist effects in some tissues and estrogen-antagonist effects in others; the second group includes the aromatase inhibitors (AI), important enzymes for peripheral estrogen conversion. Some studies compare or associate classic AE with the new SERMs and AI, both in adjuvant therapy and in treatment for advanced forms. Other trials assess the anti-osteoporotic activity of some SERMs which present concomitant inhibitory activity on the breast and endometrium.

[Consent to transfusion of blood and hemoderivatives]. / Consenso alle trasfusioni di sangue ed emoderivati.

The transfusion of blood or hemoderivatives is a medical procedure that necessarily involves the possibility of danger or damage, given that, even with maximum prudence, diligence and expertise, it is impossible to avoid severe risks of infections, transfusional reactions, alloimmunisation, undesired immunomodulating effects, etc. Article 19 of Ministerial Decree 15/01/1991 makes it obligatory to obtain informed consent , understood as the free expression of the acceptance of treatment provided after being fully informed of the nature, possibility, risks and collateral effects of the procedure. Consent to blood transfusion can only be given by a person with full mental faculties, whereas transfusion treatment can be proposed for a minor, for a prisoner or for a person who is temporarily incapacitated by their physical conditions. The authors examine a number of problems regarding the following questions: what happens if consent is withheld? What can happen if consent is not requested or if the transfusion is performed when consent has been denied? In conclusion, it is difficult to offer operating schemes that are easy to apply: much depends on the patient's conditions, his reactions, his concerns, his trust in the doctor and the latter's communication skills.

[A new organizational model of hospitals and law]. / Il nuovo modello organizzativo degli ospedali e la giustizia.

One of the more important legislative news in Italy is the company management of the National Health Care. The Health Care System has a long time budget and a yearly time budget, which allow to achieve some objectives identified inside an organizing system, based on Departments and their Directors. Another point is the competitivity among public/public and public/private structures. The problem of the penal responsibility of the medical doctor and staff is discussed.

[Preventable perinatal mortality]. / La preventabilità della mortalità perinatale.

BACKGROUND: Using a critical systematic analysis of perinatal mortality, this study aims to examine, on the basis of current medical and scientific knowledge, whether there are still situations in which feto-neonatal death could be prevented and to define and evaluate the feasibility of realising this goal. METHODS: The concept of preventable feto-neonatal death refers to the number of individuals who could have survived with better pre-, intra and postnatal care. In other words, it indicates the number of deaths that could have been avoided in an almost perfect health organisation and therefore, by reference, the number of inevitable deaths (not preventable). In this field it is important to distinguish between clinically preventable, where there are preventable factors at the time of hospitalisation and during the clinical phase of the disease, and extra-clinically preventable when these factors, if potentially present during the preclinical phase of disease, disappear owing to the gravity of conditions at the time of hospitalisation. Using data from maternal and neonatal clinical records, death certificates and autopsy findings, the authors examined the perinatal mortality rate in Department B of the Gynecological and Obstetrics Clinic of Turin University during the period 1979-1998. The results of these two decades were compared in terms of clinical practice. RESULTS: The perinatal mortality rate fell significantly (p<0.01) during the period 1989-1998: 1.02 vs 1.77%. It is worth underlining that this was mainly the result of a marked reduction (over 50%) in late fetal mortality: 0.43 vs 0.98% (p<0.01). Early neonatal mortality also diminished, although not significantly (0.59 vs 0.79%). In order to evaluate preventable deaths, perinatal mortality was subject to a detailed critical analysis to analyse its chronological evolution: prenatal, intranatal, early neonatal. During the second period examined, the preventable nature of perinatal mortality, although slightly lower, applied to 36.35% of cases. It is important to underline that although clinically preventable deaths were unfortunately still present (approx. 10%), most cases (approx. 90%) referred to extra-clinically preventable deaths. CONCLUSIONS: On the basis of current medical and scientific knowledge, the authors outline the directives for medical and specialist obstetric and social care required in the specific fight against preventable perinatal deaths. Recent progress in basic scientific research, especially in the genetic field, may make a vital contribution to limit and reduce the coefficient of feto-neonatal pathology that is still beyond control.

[Delivery in multiple pregnancies]. / Il parto nelle gravidanze multiple.

BACKGROUND: A knowledge of clinical physiognomy in pathologies related to multiple births is indispensable for improving maternal and feto-neonatal prognosis. This study is a contribution to the solution of this problem. METHODS: A meta-analysis of data for multiple births at Department B of the Gynecology and Obstetrics Clinic at the University of Turi during the decade 1989-1998 was carried out, focusing on the arrangement and presentation of fetuses, the various types of birth, the gestational age at which birth occurred, the weight of neonates, neonatal mortality and maternal morbidity. RESULTS: Out of 11,523 births, there were a total of 194 (1.68%) multiple births, including 190 sets of twins and 4 triplets. 154 (79.38%) premature births were reported; 20 occurred <32(nd) week (10.29%). There was a high incidence of podalic presentation (26.30%) and shoulder presentation (5.61%) among twins; 202 were delivered using a cesarian section (51.53%) and 190 by vaginal birth (48.47%), of which 172 (90.52%) spontaneously. Surgical birth was an important means of extracting fetuses rapidly from a pathological environment. two hundred and sixty-two neonates (66.84%) were LBW (<2500 g), including 28 (7.14%) VLBW (>1500 g). The perinatal mortality rate was 3.82%. Maternal complications mainly occurred during the placental state, in the immediate postpartum and in puerperio. CONCLUSIONS: The authors feel that a more careful medical and social assistance, preventive hospitalisation, early recognition of the risk, constant monitoring for the optimal timing of birth, and lastly, qualified medical assistance during labour (expert gynecologist, trained obstetric staff) with other medical personnel (anesthetist, neonatal specialist) represent winning strategies to solve the problems arising during multiple pregnancies.

[HRT: state of the art]. / HRT: lo stato dell'arte.

Hormone replacement therapy (HRT) in postmenopause represents the most advanced frontier of preventive medicine in a rapidly evolving society that aims to emphasise, today as in the past, the leading role of women. While modern medicine has extended the average life expectancy of women today, it is now the task to enhance the quality of these extra years. HRT prevents cardiovascular disease, osteoporosis, disorders relating to changes in pelvic connective tissue and genitourinary tissues, and it can also have a positive influence on the psycho-affective sphere and, perhaps, alterations in cognitive capacity. Cultural delays and alternate phases of optimism and alarm are not always backed by solid scientific knowledge. Epidemiological research over the past years has underlined the oncological risk of using estrogens, even if associated with progestin, without the necessary methodological clarity and efficacy. From the data reported in the international literature and on the basis of over ten years experience accumulated at Department B of Gynecology and Obstetrics of Turin University, it appears that the oncogenic risk in women taking HRT is not significantly higher if the indications are strictly respected and, when necessary, progestin is associated with estrogen.

[Embryo-fetal diseases in multiple pregnancies]. / La embrio-fetopatie nelle gravidanze multiple.

BACKGROUND: Embryo-fetal diseases are the consequence of prenatal (progenetic and metagenetic or environmental) and intranatal (of a traumatic, infective, toxic nature) pathological factors. In multiple pregnancies this complex etiopathogenesis also includes an altered didymous embriogenesis. This study aimed to evaluate the pathologies affecting the fetus in multiple pregnancy, a special biological situation leading to the potential onset of severe fetal and neonatal damage. METHODS: The authors studied 205 patients with multiple pregnancies, including 199 bigeminal, 5 trigeminal and 1 quadrigeminal, admitted to the Department B of the Obstetrics and Gynecological Clinic of Turin University between 1989-1999. Possible embyro-fetal damage was examined using a chronological criterion: namely following the development of the multiple fetuses from the zygotic to the neonatal phase. RESULTS: Pregnancies were biamniotic bichorionic in 54% of cases, biamniotic monochorionic in 45% and monochorionic monoamniotic in 1%. There were a total of 154 (79.38%) premature births out of 194 and neonatal birth weight was always SGA (small for gestational age). 66.84% of newborns were LBW (<2500 g) and 7.14% were VLBW (<1500 g). Fetal mortality (2.29%) was higher than early neonatal mortality (1.53%). Perinatal mortality (3.82%) was three times higher than in all neonates from the same period (1.03%). CONCLUSIONS: The severe embryo-fetal and neonatal damage found in multiple pregnancies is a clinical reality that calls for adequate diagnostic and therapeutic measures, and above all specific medical and social prevention to limit maternal pathogenic risks.

[Ethical problems concerning artificial fecondation]. / Problematiche morali inerenti alla fecondazione artificiale.

In view of the seriousness of the facts regarding artificial fecondation as reported in the news and by the mass media, the various experiments carried out are analysed from the anthropological and ethical points of view. The purpose of these experiments is the procreation of a person and all those who are implicated in vital decisions-physicians, nurses, legislators and families-are invited to refrain from carrying out experiments or actions that might be damaging to the dignity of people and the couple in question.

[Observations on vaginal delivery in women with previous cesarean section]. / Considerazioni attuali sull'assitenza al parto delle donne con pregresso taglio cesareo.

BACKGROUND: The significant increase in cesarean sections both before (52.73%) and during labour (89.82%) observed in the 1990s compared to the period 1970-1980 prompted the authors to review the cases of women admitted to Department B of the Gynecology and Obstetrics Clinic at the University of Turin and to study the number of women with previous cesarean sections undergoing labour. The aim of this study was to throw light on this complex question and to reduce the incidence of surgical births wherever possible. METHODS: Two groups of pregnant women with previous cesarean sections were studied in Department B of the Gynecology and Obstetrics Clinic at the University of Turin: one group included women undergoing cesarean sections between 1990-1998, and the other included women undergoing cesarean sections between 1970-1980. The authors analysed the indications for repeat cesarean section and the percentage of vaginal births. RESULTS: The results show that during 1970-1980 the percentage of vaginal births was 24.34% (259 vaginal births out of 1593 patients), whereas between 1990-1998 the percentage of vaginal births fell to 10.18% (51 vaginal births out of 1060 patients). CONCLUSIONS: The high percentage of repeat cesarean sections found in the 1990s is not only due to strictly medical reasons, but also to ethical and political motives, and above all the maternal desire not to undergo natural labour.

[Maternal morbidity in multiple pregnancies]. / La patologia gravidica nelle gravidanze multiple.

BACKGROUND: This study aimed to outline the clinical physiognomy of maternal morbidity in multiple pregnancies in order to improve maternal and feto-neonatal. METHODS: We reviewed the admissions to Department B of the Gynecology and Obstetrics Clinic at Turin University during the decade 1989-1998. Out of 17,445 pregnancies, we noted a 205 multiple pregnancies (1.17%), including 199 sets of twins, 5 triplets and 1 quadruplets. The percentages for the incidence of the various forms of maternal morbidity were compared to a control group of 1000 single births. RESULTS: Of 205 multiple pregnancies, 169 (82.43%) presented complications of varying severity and associated with statistically significant increase (always over 50%). These took the form of: premature birth (75.12%), PROM (28.29%), threat of premature birth (14.63%), phlebectasia (9.75%), anemia (8.78%), hyperemesis in the first quarter (8.29%), abortion (4.89%), polyhydramnios (4.39%), urinary tract infection (1.95%), detachment of the placenta (1.95%), liver pathology (1.46%), placenta previa (0.97%). CONCLUSIONS: The pathological picture revealed by this survey may seriously jeopardise the normal evolution of pregnancy, with severe repercussions for mother and fetus-neonate. These high-risk pregnancies should be included in a preventive programme of medical-social-outpatient and home assistance to guarantee early hospitalisation.

Pathologic features of endometrial carcinoma in elderly women.

It has been estimated that more than two-thirds of cancers occur in people over 65 years of age: endometrial cancer (EC) is the most common gynaecologic cancer in the U.S. and represents the fourth most common malignancy in women. Some authors have reported that EC in elderly women was more aggressive, histologically less-differentiated and often non-endometrioid when compared with EC in the younger population. The purpose of this retrospective study is to evaluate the pathologic features of EC in women 70 years old or over compared with those of younger patients. Between 1987 and 1997, 174 patients with EC were surgically treated: 52 women were 70 years old or over. Two-thirds of both groups had surgical Stage I tumors: 54% of surgical Stage I tumors in the elderly had myometrial invasion more than 50% compared with 32% in the younger group (p<0.01). On the whole 37% of elderly patients had Stage IC tumors compared with 21% in younger women (p<0.01). Seventy-five percent of elderly women had Grade 2 or 3 tumors compared with 55% of younger patients (p<0.005). The majority of EC was endometrioid in both groups: 8% of elderly patients had clear-cell carcinomas compared with 4% of younger women (p not significant). No elderly patients showed nodal metastasis (0 out of 10): 9% of younger women had pelvic or para-aortic metastasis. The median follow-up was 78 months. The overall survival in the elderly and in the younger group was 80% and 93%, respectively (p<0.01): in elderly women overall survival significantly varied according to histotype and depth of myometrial invasion in Stage I tumors. In conclusion patients 70 years old or over have a high probability of surgical Stage I EC but a significantly higher probability of deep myometrial invasion and less-differentiated tumors than younger women: the prognosis w as good but poorer than for younger patients.

[Early protected discharge of the mother and the neonate: case-control study]. / Dimissione precoce protetta della madre e del neonato: studio caso-controllo.

Aim of this study is to compare traditional post-partum hospital stay to hospitalization associated with early protected discharge: a case-control study has been performed to evaluate outcome as mother's appreciation of the experience as well as breastfeeding. The study included 50 healthy-term newborns and their mothers, discharged within 24 and 48 hours of life, and 44 controls, who had traditional "rooming-in" stay, delivered at the Department of Neonatology--University of Turin. The protocol included a midwife daily home visits and a neonatologist and nurse visit within 4th to 5th day of life, to evaluate mother's and baby's health status and to perform metabolic screenings. An ambulatorial follow-up visit at 1 month of life and 2 telephone interviews, at 3rd and 6th month, were also planned. During the first week of life 45 (90%) early discharged newborns had complete nursing (breastfeeding + water or other fluids), 4 (8%) had complementary nursing (breastfeeding + formula) and 1 (2%) received formula. Among controls, 46 (92%) babies received complete nursing, 2 had complementary nursing and 2 had artificial nursing. At 6 months of life breastfeeding was complete for 2% of cases and 6% of controls; in 44% of cases and 56% of controls nursing was complementary. Readmissions to our Birth Center were 2 among early discharged newborns, 1 in the control group. About project's appreciation, 96% of early discharged and 98% of control group mothers declared their availability to repeat the experience. Caring and supporting were judged adequate in 94% of both group. By adequate supporting of mother and newborn, short and traditional hospitalization are both pleasant and don't seem to present significant differences in type and length of nursing.

[Osteopoikilosis--skin and joint manifestations]. / Osteopoikilie--Haut- und Gelenkmanifestationen.

Osteopoikilosis (Osteopathia condensans disseminata) is a rare and usually asymptomatic sclerosing bone dysplasia of unknown origin. Familial clustering suggests a dominant inheritance. The observation of a 47-year-old woman lead to differential diagnostic considerations in view of the literature on about 350 cases. For 2 years the patient has been complaining about pain and stiffness of both hands with swelling of the fingers. Additionally, she remarked about bilateral paresthesias corresponding to the sensory innervation of the median nerve. Clinical examination revealed a sensory carpal tunnel syndrome and mild synovitis of the proximal interphalangeal joints with skin induration and limited flexion of the fingers. In addition, some finger and toe nails showed pitting and most fingers had scar-like linear skin alterations. Radiologic findings showed symmetric, well-defined, homogeneous sclerosing areas in spongy bone. The combination of symmetrical sclerosing bone densities, hereditary character, and associated skin and joint manifestations suggests the existence of a general connective tissue disease.

Thyroiditis due to Brucella melitensis--report of two cases.

Two cases of thyroiditis due to Brucella melitensis are reported. Both occurred in foreigners working in Switzerland and presented with characteristic symptoms of thyroiditis which masked those of brucellosis. Cultures were diagnostic. One patient had concomitant thyroid malignancy. Both showed normal thyroid function and were cured following antibiotic treatment.