A Ten-Year Review of Antenatal Complications and Pregnancy Outcomes Among HIV-Positive Pregnant Women.

OBJECTIVE: To review the incidence of antenatal complications among a cohort of HIV-positive pregnant women over a 10-year period. METHODS: A retrospective review was performed of all HIV-positive pregnant women receiving multidisciplinary prenatal care at an urban tertiary care centre from March 2000 to March 2010. Collected data included the presence of additional infectious or medical conditions, genetic screening information, and the presence or absence of antenatal complications. RESULTS: One hundred and forty-two singleton pregnancies during the study period were identified. Almost 95% of women were taking combination antiretroviral therapy during pregnancy, and greater than 90% had viral loads less than 1000 copies/ml at delivery. The presence of co-infections was low. Forty-one women (29%) had other medical comorbidities. Genetic screening occurred in 104 pregnancies (73%); 4% were abnormal screens. Rates of any hypertension, gestational diabetes, and fetal growth restriction were all low. Thirty-two percent of women were colonized with group B streptococcus. CONCLUSION: This study adds strength to the argument that good outcomes can be achieved for HIV-positive pregnant women with good access to both prenatal and HIV care, and appropriate management. Women with HIV should be optimally cared for in advance of and during pregnancy in order to maximize the likelihood of good pregnancy outcomes.

Terminal Ileum Lipoma Causing Ileocolic Intussusception: A Case Report and Literature Review.

Adult intussusception is much rarer than pediatric intussusception and usually occurs secondary to a pathological lead point, most frequently neoplasm. Terminal ileum lipomas are an infrequent cause of adult ileocolic intussusception but can be seen together with the intussusception on initial imaging evaluation, which can guide appropriate diagnosis and management. We describe a case of a 42-year-old man presenting with 12 hours of severe right lower quadrant pain. CT of the abdomen and pelvis demonstrated an ileocolic intussusception with fat-density lesions within the intussusception as well as in the distal ileum. The patient went to the operating room for laparoscopic ileocolic resection, during which ileo-ileal and ileocolic intussusceptions were identified in the terminal ileum and multiple fatty masses were palpated in the terminal ileum and cecum. Following ileocecectomy, surgical pathology confirmed terminal ileum with intussusception associated with multiple submucosal lipomas. We also review the literature for cases of ileocolic intussusception caused by terminal ileum lipomas. Patients presented with both acute and chronic symptoms, and while CT was the most common modality used for diagnosis, ultrasound and colonoscopy were also able to identify the intussusception. Although the intussusception was initially reduced in two patients, all patients ultimately underwent surgical resection.

Adverse pregnancy outcomes among foreign-born Canadians.

OBJECTIVE: Numerous non-Canadian studies have shown that immigrant women experience higher rates of adverse maternal and perinatal events than the general non-immigrant population. Limited information about the pregnancy outcomes of immigrant Canadian women is available. METHODS: We conducted a retrospective cohort study at St. Michael's Hospital between October 2002 and June 2006 to estimate the risk of adverse obstetrical and perinatal outcomes among foreign-born women residing in Toronto. The main study outcomes were the incidences of preterm delivery between 32 and 36 completed weeks' gestation, low infant birth weight, and delivery by Caesarean section. RESULTS: Compared with Canadian-born women, those who were foreign-born had an associated adjusted odds ratio of 0.85 (95% CI 0.64 to 1.14) for preterm delivery, 1.92 (95% CI 1.29 to 2.85) for low infant birth weight, and 1.16 (95% CI 1.01 to 1.34) for delivery by Caesarean section. CONCLUSION: In this study, foreign-born women had a non-significantly lower risk of preterm birth, but a significantly higher risk of low birth weight infants and Caesarean section than Canadian-born women. In this urban setting, recent immigrant women have worse pregnancy outcomes, warranting increased attention to this group during antenatal and intrapartum care.

MRI findings in the painful poststroke shoulder.

BACKGROUND AND PURPOSE: We describe the structural abnormalities in the painful shoulder of stroke survivors and their relationships to clinical characteristics. Method- Eighty-nine chronic stroke survivors with poststroke shoulder pain underwent T1- and T2-weighted multiplanar, multisequence MRI of the painful paretic shoulder. All scans were reviewed by one radiologist for the following abnormalities: rotator cuff, biceps and deltoid tears, tendinopathies and atrophy, subacromial bursa fluid, labral ligamentous complex abnormalities, and acromioclavicular capsular hypertrophy. Clinical variables included subject demographics, stroke characteristics, and the Brief Pain Inventory Questions 12. The relationship between MRI findings and clinical characteristics was assessed through logistic regression. RESULTS: Thirty-five percent of subjects exhibited a tear of at least one rotator cuff, biceps or deltoid muscle. Fifty-three percent of subjects exhibited tendinopathy of at least one rotator cuff, bicep or deltoid muscle. The prevalence of rotator cuff tears increased with age. However, rotator cuff tears and rotator cuff and deltoid tendinopathies were not related to severity of poststroke shoulder pain. In approximately 20% of cases, rotator cuff and deltoid muscles exhibited evidence of atrophy. Atrophy was associated with reduced motor strength and reduced severity of shoulder pain. CONCLUSIONS: Rotator cuff tears and rotator cuff and deltoid tendinopathies are highly prevalent in poststroke shoulder pain. However, their relationship to shoulder pain is uncertain. Atrophy is less common but is associated with less severe shoulder pain.

Placenta accreta: spectrum of US and MR imaging findings.

Placenta accreta (PA) encompasses various types of abnormal placentation in which chorionic villi attach directly to or invade the myometrium. PA is a significant cause of maternal morbidity and mortality and is now the most common reason for emergent postpartum hysterectomy. Its prevalence has risen tenfold in the United States over the past 50 years, primarily due to the increasing percentage of pregnant patients undergoing primary and repeat cesarean sections. Placenta previa and previous cesarean section are the two most important known risk factors for PA. Accurate prenatal identification of affected pregnancies allows optimal obstetric management. Ultrasonography (US) remains the diagnostic standard, and routine US examination at 18-20 weeks gestation affords an ideal opportunity to screen for the disorder. Placental lacunae and abnormal color Doppler imaging patterns are the most helpful US markers for PA. In recent years, there has been increased interest in magnetic resonance (MR) imaging for the evaluation of PA, since it can provide information on depth of invasion and more clearly depict posterior placentas. The most reliable MR imaging findings are uterine bulging, heterogeneous placenta, and placental bands. Focal interruptions in the hypointense myometrial border may also be helpful. PA is a clinical and diagnostic challenge that is being encountered with increasing frequency. Clinicians should be aware of the clinical issues, risk factors, and imaging findings associated with PA to facilitate optimal case management.

Influence of an "opt-out" test strategy and patient factors on human immunodeficiency virus screening in pregnancy.

OBJECTIVE: To estimate both human immunodeficiency virus (HIV) testing acceptance rates in pregnancy using an opt-out policy and patient characteristics influencing acceptance. METHODS: At the first prenatal visit, HIV testing was offered using an opt-out approach. Reasons for refusing testing were explored. Demographic information was collected on all study subjects. RESULTS: In the prospective portion of the study, 1,140 of 1,233 women (92.5%) accepted testing. Race was predictive of accepting HIV testing, with Asian women significantly less likely (odds ratio [OR] 0.4; 95% confidence interval [CI] 0.3-0.6; P<.001) and Hispanic women significantly more likely (OR 6.9; 95% CI 2.2-22.0; P=.001) to be tested. Although English as a first language, country of birth, and insurance status were not significantly associated with acceptance, women who were fluent in English were more likely to be tested (OR 2.0; 95% CI 1.2-3.3; P=.01). Our testing rates were significantly higher than the provincial average. CONCLUSION: Using an opt-out strategy, HIV testing rates in our clinic were significantly higher than the provincial average. Rates were influenced by race and fluency in English.

Is magnetic resonance imaging essential in clearing the cervical spine in obtunded patients with blunt trauma?

BACKGROUND: The optimal method of clearing the cervical spine (CS) in obtunded blunt trauma patients (OBTPs) remains unclear. Computed tomography (CT) identifies most injuries but may fail to detect ligamentous and spinal cord injuries. Magnetic resonance (MR) imaging has been widely used to exclude these. The purpose of this study was to evaluate whether CT of the CS (CT-CS) alone is adequate to clear the CS in OBTPs. Our hypothesis was that MR imaging of the CS (MR-CS) does not contribute relevant information and is not necessary in this patient population. METHODS: A prospective evaluation of OBTPs with a CT-CS negative for acute trauma and an MR-CS obtained for clearance was performed at a Level I trauma center between July 1, 2004, and June 30, 2006. Data gathered included demographics, results of CT-CS and MR-CS, timing of MR-CS, Glasgow Coma Scale score at time of MR-CS, adverse events occurring while obtaining MR-CS, and cervical collar complications. RESULTS: One hundred and fifteen patients were identified. There were 90 male patients. The mean age was 43.9 years +/- 1.9 years, mean Injury Severity Score was 24.4 +/- 1.0, and mean length of stay was 23.4 days +/- 1.2 days. The MR-CS was performed on hospital day 7.5 +/- 0.6 and the mean Glasgow Coma Scale score at the time of MR-CS was 8.3 +/- 0.3. Six MR-CS (5.2%) subsequently identified acute injuries. Findings included microtrabecular injuries, intraspinous ligament injuries, a cord signal abnormality, and a cervical epidural hematoma. None of these findings changed management and none required continued cervical collar usage. Six cervical collar complications were identified (5.2%). No adverse events related to transport or obtaining MR-CS occurred. Eliminating MR-CS would have decreased health care costs by over $250,000 during this period. CONCLUSIONS: MR-CS may be unnecessary in the OBTP if the CT-CS is negative. Elimination of MR-CS in this population will lead to earlier removal of cervical collars, decreased cervical collar complications, protection of the patient from exposure to potential risks inherent to obtaining this study, and decreased health care costs.