Breech progression angle: new feasible and reliable transperineal ultrasound parameter for assessment of fetal breech descent in birth canal.

OBJECTIVE: To assess the feasibility and reliability of transperineal ultrasound in the assessment of fetal breech descent in the birth canal, by measuring the breech progression angle (BPA). METHODS: Women with a singleton pregnancy with the fetus in breech presentation between 34 and 41 weeks' gestation were recruited. Transperineal ultrasound images were acquired in the midsagittal view for each woman, twice by one operator and once by another. Each operator measured the BPA after anonymization of the transperineal ultrasound images. BPA was defined as the angle between a line running along the long axis of the pubic symphysis and another line extending from the most inferior portion of the pubic symphysis tangentially to the lowest recognizable fetal part in the maternal pelvis. Each operator was blinded to all other measurements performed for each woman. Intra- and interobserver reproducibility of BPA measurement was evaluated using the intraclass correlation coefficient (ICC). To investigate the presence of any bias, intra- and interobserver agreement was also analyzed using Bland-Altman analysis. Student's t-test and Levene's W0 test were used to investigate whether a number of different clinical factors had an effect on systematic differences and homogeneity, respectively, between BPA measurements. RESULTS: Overall, 44 women were included in the analysis. BPA was measured successfully by both operators on all images. Both intra- and interobserver agreement analyses showed excellent reproducibility in BPA measurement, with ICCs of 0.88 (95% CI, 0.80-0.93) and 0.83 (95% CI, 0.71-0.90), respectively. The mean difference between measurements was 0.4° (95% CI, -1.4 to 2.2°) for intraobserver repeatability and -0.4° (95% CI, -2.6 to 1.8°) for interobserver repeatability. The upper limits of agreement were 12.0° (95% CI, 8.9-15.1°) and 13.6° (95% CI, 9.9-17.3°) for intra- and interobserver repeatability, respectively. The lower limits of agreement were -11.2° (95% CI, -14.3 to -8.1°) and -14.4° (95% CI, -18.2 to -10.7°) for intra- and interobserver repeatability, respectively. No systematic difference between BPA measurements was found on either intra- or interobserver agreement analysis. None of the clinical factors examined (maternal body mass index, maternal age, gestational age at the ultrasound scan and parity) showed a statistically significant effect on intra- or interobserver reliability. CONCLUSIONS: BPA represents a new feasible and highly reproducible measurement for the evaluation of fetal breech descent in the birth canal. Future studies assessing its usefulness in the prediction of successful external cephalic version and breech vaginal delivery are needed. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Effects of a new aminodiphosphonate (aminohydroxybutylidene diphosphonate) in patients with osteolytic lesions from metastases and myelomatosis. Comparison with dichloromethylene diphosphonate.

We have compared in an open trial the clinical and biochemical effects of a new aminodiphosphonate, aminohydroxybutylidene diphosphonate, with those of dichloromethylene diphosphonate, which has been proved effective. The patients presented extensive and symptomatic bone involvement from multiple myeloma, breast cancer, and other metastatic tumors. The treatment consisted of aminohydroxybutylidene diphosphonate, 2.5 mg/d intravenously for five days, or dichloromethylene diphosphonate, 300 mg/d intravenously for seven days, followed by 100 mg/d intramuscularly for ten days. Twelve patients treated with aminohydroxybutylidene diphosphonate and 16 patients treated with dichloromethylene diphosphonate were assessable and were followed up for one to six months. Therapy with aminohydroxybutylidene diphosphonate showed a quicker action in reducing bone pain and reduced significantly more the serum calcium level than did therapy with dichloromethylene diphosphonate. Aminohydroxybutylidene diphosphonate therapy also affected urinary calcium levels and hydroxyproline excretion more markedly than did dichloromethylene diphosphonate, although the differences are not statistically significant. However, the biochemical indexes rebounded more quickly in patients treated with aminohydroxybutylidene diphosphonate, indicating that the loading amount (only 12.5 mg) used in this preliminary study is insufficient to sustain a prolonged effect. The effectiveness and lack of side effects render aminohydroxybutylidene diphosphonate an attractive treatment for malignant bone resorption.

[Surgical treatment of rectal cancer: prognostic factors for long-term survival]. / Trattamento chirurgico del cancro del retto: fattori prognostici per la sopravvivenza a lungo termine.

The aim of our retrospective study was to verify the results of surgical treatment of rectal cancer in a homogeneous case series, evaluating the various factors that can influence the prognosis and long-term results. The prognostic factors taken into consideration were: Duke's stage; grading; colloid component; location of tumour; type of surgical intervention; age; sex; duration of the symptoms; length of normal rectum below the lower border of the tumour correlated to stage and grading. One hundred and sixty-five patients were operated with a radical approach: 50 abdominoperineal resections (APR) and 115 sphincter-saving resections (SSR) were performed. There were 90 males and 75 females. The mean age was 63 years. Total survival was 61.7% after 5 years and 50% after 10 years. In our study neither the age nor the sex, duration of symptoms or location of the tumours proved to have an influence on survival; while Duke's state turned out to be decisive for survival; also the colloid tumour component proved to have a worse prognosis. The 5-10-year survival rate was respectively 53.6% and 49% in the APR and 65.7% and 50.9% in the SSR (p = n.s.). The data we have collected show that APR and SSR operations have analogous efficiency.

[Removal of Douglas's pouch - a review of 50 cases]. / Etude critique de 50 douglassectomies.

The authors demonstrate the innocuousness of the method of removal of the Pouch of Douglas after a critical analysis of 50 cases followed up for between 6 months and 5 years. They believe that simple removal of the pelvic peritoneum is sufficient to overcome the condition of a pathological fold of peritoneum, but not sufficient on the other hand to correct the condition of retroverted uterus because two new peritoneal fossae form lateral to the viscerae easily because of the morphology of the pelvic cavity. They therefore stress that, at the time of the operation, it is important to suture the utero-sacral ligaments together in the sagittal plane.

[Systematic inhibition of the luteinizing hormone with a gonadoliberin analog, triptorelin, during ovarian stimulation for fertilization in vitro. Choice of protocol]. / Inhibition systématique de l'hormone lutéinisante par un analogue de la gonadolibérine, la triptoréline, au cours de la stimulation ovarienne pour fécondation in vitro. Choix du protocole.

The quality of ovarian stimulation for in vitro fertilization with or without an LH-RH analogue was investigated in a randomized trial involving 30 women divided into 3 groups. Group I women were treated with the conventional clomiphene citrate-human menopausal gonadotropin combination without LH-RH analogue. Group II women (long regimen) received a slow-release preparation of triptorelin (DTRp6-LH-RH), an LH-RH analogue, and human menopausal gonadotropin. Group II women (short regimen) were given triptorelin with human menopausal gonadotropin. Inhibition of the endogenous luteinizing hormone using triptorelin improved the results of in vitro fertilization in group II and group III women, but the short regimen was distinctly less compelling and less expensive than the long regimen.

Diagnostic value of serum immunoreactive conjugated cholic or chenodeoxycholic acids in detecting hepatobiliary diseases. Comparison with levels of 3 alpha-hydroxy bile acids determined enzymatically and with routine liver tests.

The diagnostic value of the enzymatic fluorometric method for total serum bile acids (TSBA) and for radioimmunoassay measurement for conjugated cholic acid (CCA) or chenodeoxycholic acid was compared with that of routine liver function tests in 223 patients with liver disease, 88 healthy subjects, and 118 patients affected by other diseases. The value of the tests for screening in the general population was assessed by simulation, using estimates of disease prevalence. TSBA was significantly more sensitive (78%) but less specific (94%) than CCA (sensitivity of 69%, specificity of 98%). Aspartate aminotransferase was nearly as sensitive (74%) as TSBA, but significantly less specific (93%) than CCA. CCA provided the highest positive predictivity (98%), even in a screening simulation (32%). With the use of sequential aspartate aminotransferase measurement followed by CCA, this value rose to 100%. This test procedure appears to be the best screening method for liver diseases available at present.

Acute pancreatitis during oral 5-aminosalicylic acid therapy.

Therapy with oral 5-aminosalicylic acid for inflammatory bowel disease has been reported as effective and safe. We report two cases of biochemically proven mild acute pancreatitis occurring 2 and 14 days, respectively, after oral 5-aminosalicylic acid therapy was instituted for inflammatory bowel disease. A hypersensitivity mechanism might be involved, owing to possible erratic systemic absorption of the drug. We suggest clinical and biochemical monitoring for patients undergoing oral 5-aminosalicylic acid therapy in order to confirm its possible association with acute pancreatitis and to assess the actual incidence of such an adverse reaction.

Reference values of maximal respiratory mouth pressures: a population-based study.

The aim of our study was to measure values of maximal inspiratory (MIP) and expiratory (MEP) mouth pressures in 625 (266 male, 359 female) clinically and functionally normal subjects drawn out of a sample representative of the general population. MEP (near TLC and FRC) was found to be significantly higher when compared with MIP (near RV and FRC), and pressures in male subjects were significantly higher than those in female subjects. MEP values at TLC and FRC were found to be closely related, as were values of MIP near RV and near FRC. Among the tested body-size variables, body surface area (BSA) for all parameters had the highest degree of correlation. Stepwise linear regression analysis was performed to define the equation of normality for all four parameters, employing BSA, sex, age, and relative interaction terms. R2 values, although the variables employed for the equations were highly significant, were relatively low and didn't fully explain the source of variability. The influence of age was smaller than the influence of BSA, although age did reduce the unexplained variance in MEP and MIP. These results confirm that the most useful employment of MIP and MEP is to monitor their changes in each patient, but they point out, however, the usefulness of reliable reference equations.

[Antipyrine clearance in liver resections]. / La clearance dell'antipirina nelle resezioni epatiche.

We studied antipyrine clearance (APC1) in 19 healthy controls, 10 cirrhotic patients, 20 patients undergoing partial hepatectomy for liver tumors (14 with cirrhosis and 6 without cirrhosis). The aim of the study was to evaluate if the test represents a measure of the residual hepatic function and a useful index of surgical risk in cirrhotic patients following partial hepatectomy. The APC1 was significantly reduced in cirrhotic patients ws healthy controls. It is reduced following partial hepatectomy in cirrhotic patients (p less than 0.001) and in non cirrhotic patients (n.s.). The APC1 was found to be related with the plasma level of albumin and pseudocholinesterase; it also was related with the Pugh's score for hepatic function. The APC1 is a satisfactory index of residual hepatic function. On the other hand it does not provide more useful information than the Pugh's score for surgical risk in liver resection.

Diagnostic value of serum bile acids and routine liver function tests in hepatobiliary diseases. Sensitivity, specificity, and predictive value.

Total serum bile acids measured by enzymatic fluorometry and routine liver function tests were determined in a large population including 97 healthy subjects, 138 patients free of hepatobiliary diseases but affected by other diseases, and 344 patients with mild or severe hepatobiliary diseases. In order to define the diagnostic value and some operational characteristics of serum bile acids, sensitivity, specificity, and several predictive value tables for increasing cutoff levels of serum bile acids were calculated by means of a computer program. Serum bile acids and aspartate aminotransferase were found to be similar in sensitivity, specificity, and predictive value. Serum aspartate aminotransferase was found to be more suitable than serum bile acids in detecting mild hepatobiliary diseases, whereas serum bile acids were more sensitive than routine liver tests in the evaluation of severe hepatobiliary diseases. In view of its ability to detect severe hepatobiliary diseases, serum bile acids test may play a decisive role in clinical practice (eg, decision to perform a liver biopsy).

Enzymatic determination of faecal bile acids. A simple test for bile acid malabsorption.

A simple method for total faecal bile acid (FBA) determination was carried out. This test involves a 72 hour stool collection, homogenization and FBA determination by means of an enzymatic-fluorimetric method (3 -Hydroxysteroid-dehydrogenase). The reliability of this test was discussed. FBA levels were tested in twelve healthy volunteers. In addition, two patients with bile acid malabsorption syndrome due to terminal ileitis and one patient with cholegenic diarrhoea caused by biliocolonic fistula were examined. The mean +/- SD of FBA values in healthy subjects was 0.49 +/- 0.3 g/72 hours. However, all patients tested show a marked increase of FBA levels. In conclusion the present method for bile acid determination in the faeces seems to be a useful tool in the diagnosis of bile acid malabsorption syndrome and in cholegenic diarrhoea.

[Induction of ovulation and fertilization in vitro. Attempted optimization using an analog of LH-RH: D-Trp6-LP]. / Induction de l'ovulation et fécondation in vitro. Tentative d'optimalisation à l'aide d'un analogue de la LH-RH: le D-Trp6-LP.

The authors report the results of LH-RH blocking by an analogue for the purpose of obtaining a more constant inducement of ovulation. It concerns a delayed action product, the inconvenience of which is a possible extended action beyond thirty days, which could have an unfavorable effect on the luteal phase.

Physiology of ileoanal anastomosis with ileal reservoir for ulcerative colitis and adenomatosis coli.

A physiologic and metabolic assessment was carried out on eight patients six months after total proctocolectomy with ileal reservoir for ulcerative colitis and familial adenomatosis coli. All patients were continent and able to defecate spontaneously, stool frequency ranging from two to five per 24 hours. Anal sphincter resting pressures (35 +/- 14 mmHg) and squeeze pressures (88 +/- 24.2 mmHg) were similar to those of a healthy population, with the exception of one patient's complaint of nocturnal mucous leakage per anus. Biopsies of the ileal mucosa of the reservoirs showed a mild inflammation in seven patients; in one a subtotal villous atrophy (plus glandular pattern) was found. Anthropometric measurements, lymphocyte counts, hemoglobin, albumin, transferrin, iron, B12, and folate were normal in all. In the majority of patients there was no evidence of bacterial overgrowth. Vitamin B12 absorption was reduced slightly in only one patient. Lipid absorption (as judged by the 14C-Triolein breath test) was abnormal in three patients. Fecal clearance of alpha 1 antitrypsin as protein losses index was abnormal in three patients. Bile acid malabsorption was the most important ileal dysfunction observed in the patients.

Long-term effects of parenteral dichloromethylene bisphosphonate (CL2MBP) on bone disease of myeloma patients treated with chemotherapy.

Data on the long-term treatment of myeloma bone disease with bisphosphonates are scanty. In a prospective pilot trial we evaluated the effect of long-term parenteral administration of dichloromethylene bisphosphonate (Clodronate), in addition to standard chemotherapy, in 30 patients with active myeloma bone disease. Patients were treated with a mean of 4 courses (range 2-8) of Clodronate: 300 mg/day i.v. for seven days followed by 100 mg/day i.m. for 10 days, administered at a mean interval of 4 months (range 3-6). The median follow-up was 24 months (range 8-36). Clodronate reduced bone pain rapidly and significantly, and reduced the mean values of the biochemical indices of bone resorption to within normal limits; these effects were maintained throughout the follow-up. In three hypercalcemic episodes serum calcium became normal after 2-5 days of treatment with Clodronate. No toxic or side effects were noticed. The occurrence of skeletal morbidity in patients treated with Clodronate was compared with that observed in the control group of myeloma patients (p less than 0.001) in severe bone pain as well as in the incidence of new osteolytic lesions and pathological fractures (p less than 0.001). Supportive Clodronate therapy contributes significantly in controlling the progression of myeloma bone disease.

Age-related clinical severity at diagnosis in 1705 patients with ulcerative colitis: a study by GISC (Italian Colon-Rectum Study Group).

Clinical-endoscopic parameters of UC presentation were studied in 1705 out-patients, observed consecutively in 17 Italian gastroenterology centers (males 60.2%; average age at diagnosis 38.5 +/- 16.4 years), and were subdivided arbitrarily into quartile age groups at diagnosis (0-25, 26-35, 36-50, >50). A significantly greater prevalence in males, increasing with age, was shown at diagnosis (P = 0.0002), which seems to correlate with the condition of being an ex-smoker, most frequently found in males. The greater frequency of exsmokers could also, in part, justify the second peak of incidence in old age. Greater colitis extent, greater clinical activity, and greater use of steroids as the first therapeutic step are shown to prevail among younger patients and among women (P = 0.02 and P = 0.019, respectively). The same is observed for symptoms mainly representing clinical severity such as diarrhea, fever, and weight loss (P = 0.004; P = 0.006; P = 0.009, respectively). This study confirms the UC risk factor represented by the condition of being an ex-smoker and shows a greater severity of illness on diagnosis in younger patients.