Prediction and prevention of early-onset pre-eclampsia: impact of aspirin after first-trimester screening.

OBJECTIVE: To examine the effect of a combination of screening and treatment with low-dose aspirin on the prevalence of early-onset pre-eclampsia (PE). METHODS: This was a retrospective analysis of two consecutive cohorts of women screened for early PE. The first cohort was observed to determine whether algorithms developed to screen for PE at 11 to 13 + 6 weeks' gestation could be applied to our population. High-risk women in the second cohort were advised on their risk and offered aspirin (150 mg at night), with treatment starting immediately after screening. The prevalence of early PE and the proportion of women with PE delivering at 34-37 weeks' gestation were compared between the cohorts. RESULTS: In the observational and interventional cohorts, 3066 and 2717 women, respectively, were screened. There were 12 (0.4%) cases of early PE in the observational cohort and one (0.04%) in the interventional cohort (P < 0.01). Among all women with PE delivering before 37 weeks, 25 (0.83%) were in the observational cohort and 10 (0.37%) in the interventional cohort (P = 0.03). CONCLUSIONS: A strategy of first-trimester screening for early PE coupled with prescription of aspirin to the high-risk group appears to be effective in reducing the prevalence of early PE.

The Akt signaling pathway determines the different proliferative capacity of chronic lymphocytic leukemia B-cells from patients with progressive and stable disease.

Chronic lymphocytic leukemia (CLL) B-cells are hyporesponsive to many proliferative signals that induce activation of normal B-lymphocytes. However, a heterogeneous response has recently been observed with immunostimulatory CpG-oligodeoxynucleotides (CpG ODN). We now show that CpG ODN induce proliferation mainly in CLL B-cells from patients with progressive disease and unmutated immunoglobulin V(H) genes, whereas G(1)/S cell cycle arrest and apoptosis are induced in leukemic B-cells from stable/V(H) mutated CLL. Examination of early signaling events demonstrated that all CLL B-cells respond to CpG ODN stimulation by degradation of the NF-kappaB inhibitor IkappaB and activation of the Akt, ERK, JNK and p38 MAPK kinases, but the magnitude and duration of the signaling response was greater in the proliferating cases. Pharmacological inhibition of these pathways showed that simultaneous activation of Akt, ERK and JNK is required for cell cycle progression and proliferation. Conversely, introduction of constitutively active Akt in nonproliferating CLL B-cells resulted in induction of cyclin A following CpG ODN stimulation, indicating that increased Akt activation is sufficient to overcome the hyporesponsiveness of these cells to proliferative signals. Thus, the magnitude of Akt signaling may determine the distinct responses observed in leukemic B-cells belonging to the different prognostic subgroups.

[Environmental quality of the operating theatres in Campania: long lasting monitoring results]. / La qualità ambientale di sale operatorie nella regione Campania: i risultati di un monitoraggio pluriennale.

In this study the microbiological, physical and chemical results of an investigation concerning the environmental conditions of operating theatres in 38 public hospitals of the Campania Government are presented. The analysis of the results has been made by considering specific standards suggested by national and international regulations. The results showed that 84% of the operating theatres presented normal microbiological values, in relation to the total bacterial load, while 16% did not. By considering the microclimatic monitoring 55% of the operating theatres showed normal values while 45% at least a microclimatic index did not. In relation to the concentrations of anaesthetics gases the survey pointed out that the nitrous oxides was within non prescribed environmental limits (50 ppm for N2O); while 15% of the halogenated was not in normal values.

A Survey of Knowledge and Views Concerning Genetic and Amyloid PET Status Disclosure.

INTRODUCTION: This survey characterizes viewpoints of cognitively intact at-risk participants in an Alzheimer prevention registry if given the opportunity to learn their genetic and amyloid PET status. METHODS: 207 participants were offered a 25-item survey. They were asked if they wished to know their ApoE and amyloid PET status, and if so, reasons for wanting to know, or not, and the effects of such information on life plans. RESULTS: 164 (79.2%) of registrants completed the survey. Among those who were unaware of their ApoE or amyloid PET results, 80% desired to know this information. The most common reasons for wanting disclosure were to participate in research, to arrange personal affairs, to prepare family for illness, and to move life plans closer into the future. When asked if disclosure would help with making plans to end one's life when starting to lose their memory, 12.7% vs. 11.5% responded yes for ApoE and amyloid PET disclosures, respectively. Disclosure of these test results, if required for participation in a clinical trial, would make 15% of people less likely to participate. Likelihood of participation in prevention research and the desire to know test results were not related to scores on brief tests of knowledge about the tests. DISCUSSION: These results suggest that stakeholders in AD prevention research generally wish to know biological test information about their risk for developing AD to assist in making life plans.

Gambling and the need for new responses in Public Health with an addiction "sine substantia".

BACKGROUND: The Gambling Disorder (GD) was recently defined as a behavioral addiction by the "The Diagnostic and Statistical Manual of Mental Disorders IV"( DSM-V) since the clinical, neurobiological and psychopathological similarities led it to be defined it as an addiction "sine substantia". The aim of this study is to formulate an "identikit" of the gambler, to evaluate a possible association between GD / emotional specific factors and the correlation between GD / substance abuse, GD / suicide. METHOD: In the study, 41 subjects were included (31 males and 10 females) and all were diagnosed with GD. A questionnaire was distributed containing 24 questions deriving from South Oaks Gambling Screen and the DSM-IVTR. RESULTS: The study showed that 51% of the respondents makes use of alcohol and / or drugs; that 73% of the patients started playing in order to relieve feelings of dysphoria and suffering consequences on work as well as family life (51%). A great deal of the respondents were indebted (39%) to the extent of needing to ask for loans from usurer (17%). Furthermore, 41% of the respondents in the sample showed that GD could be transformed into an alarming risk of suicide. DISCUSSION: The correlation between GD and drug abuse may depend on the brain function and the neural circuits that support impulsive behavior and the gratification mechanisms. Emotional experiences (stress, low level of education, divorce, poor social support) could constitute a possible risk factor that increases the GD. The committed offenses related to gambling could be explained by "loss of control". CONCLUSIONS: The results of the present study contributes to the body of knowledge regarding the size of phenomenon from a statistical and epidemiological point of view, suggesting the necessity for targeted information on the risks connected to GD in order to capture early warning signs which enables the intervention with suitable strategies.

Skeletal muscle sarcoplasmic reticulum phenotype in myotonic dystrophy.

In this study we investigated the sarcoplasmic reticulum (SR), alongside myofibrillar phenotype, in muscle samples from five Myotonic Dystrophy (DM) patients and five control individuals. DM muscles exhibited as a common feature, a decrease in the slow isoform of myosin heavy chain (MHC) and of troponin C in myofibrils. We observed a match between myofibrillar changes and changes in SR membrane markers specific to fiber type, i.e. the fast (SERCA1) Ca(2+)-ATPase isoform increased concomitantly with a decrease of protein phospholamban (PLB), which in native SR membranes colocalizes with the slow (SERCA2a) SR Ca(2+)-ATPase, and regulates its activity depending on phosphorylation by protein kinases. Our results outline a cellular process selectively affecting slow-twitch fibers, and non-degenerative in nature, since neither the total number of Ca(2+)-pumps or of ryanodine receptor/Ca(2+)-release channels, or their ratio to the dihydropyridine receptor/voltage sensor in junctional transverse tubules, were found to be significantly changed in DM muscle. The only documented, apparently specific molecular changes associated with this process in the SR of DM muscle, are the defective expression of the slow/cardiac isoform of Ca(2+)-binding protein calsequestrin, together with an increased phosphorylation activity of membrane-bound 60 kDa Ca(2+)-calmodulin (CaM) dependent protein kinase. Enhanced phosphorylation of PLB by membrane-bound Ca(2+)-CaM protein kinase also appeared to be most pronounced in biopsy from a patient with a very high CTG expansion, as was the overall 'slow-to-fast' transformation of the same muscle biopsy. Animal studies showed that endogenous Ca(2+)-CaM protein kinase exerts a dual activatory role on SERCA2a SR Ca(2+)-ATPase, i.e. either by direct phosphorylation of the Ca(2+)-ATPase protein, or mediated by phosphorylation of PLB. Our results seem to be consistent with a maturational-related abnormality and/or with altered modulatory mechanisms of SR Ca(2+)-transport in DM slow-twitch muscle fibers.

Alignment of the umbilical axis: an effective maneuver for laparoscopic entry in the obese patient.

BACKGROUND: In obese patients, a panniculus may cause a caudal deviation in the vertical axis of the umbilicus and make laparoscopic entry difficult. TECHNIQUE: First, the presence or absence of caudal deviation of the umbilical axis is ascertained by measuring the distance between the external umbilical orifice and the anterior superior iliac spines along the length of the patient. Second, the caudally deviated umbilicus is displaced cranially by manual pressure on the panniculus so that the external umbilical orifice rests approximately 8 cm above the level of the anterior superior iliac spines. Third, open laparoscopy is performed through the base of the umbilicus by elevating it with clamps and incising skin, fascia, and peritoneum in a vertical axis. EXPERIENCE: In an 18-month period, 67 consecutive obese women (weight range 99-213 kg) underwent surgery by the authors for gynecologic conditions requiring primary intraperitoneal evaluation or treatment. All of these patients were scheduled for laparoscopy and underwent the assessment, alignment, and entry technique described above to commence the operations. Laparoscopic entry by this technique was successful and rapid in all 67 cases and was not complicated by preperitoneal insufflation, subcutaneous emphysema, visceral injury, vascular injury, penetration of an underlying skin fold, or postoperative wound complications. CONCLUSION: Umbilical axis assessment and alignment safely facilitates laparoscopy in obese patients.

Modified cesarean hysterectomy for placenta previa percreta with bladder invasion: retrovesical lower uterine segment bypass.

BACKGROUND: Present conservative and radical surgical management of placenta previa percreta with bladder invasion is associated with significant hemorrhage and the need for blood salvage, transfusion, and component therapy. Conventional cesarean hysterectomy strategies have high surgical morbidity, despite adequate personnel and resources. CASE: A 37-year-old, gravida 3, para 2-0-0-2, with a radiographic diagnosis of placenta previa percreta with bladder invasion, and confirmed fetal lung maturity, had a modified cesarean hysterectomy at 34 weeks' gestation. The bladder was partially mobilized beneath the percreta invasion site via the paravesical spaces. Estimated blood loss was 900 mL. Superficial placental bladder invasion was confirmed by pathology. The postoperative course was uneventful. CONCLUSION: Modified cesarean hysterectomy prevented hemorrhage and need for blood salvage, transfusion, or component therapy in managing a case of placenta previa percreta with bladder invasion.

Vaginal removal of the benign nonprolapsed uterus: experience with 300 consecutive operations.

OBJECTIVE: To determine the effectiveness and safety of vaginal hysterectomy for benign nonprolapsed uteri. METHODS: Three hundred consecutive women with nonprolapsed uteri requiring hysterectomy for benign uterine conditions, without suspected adnexal disease, were treated prospectively by vaginal hysterectomy. Twenty-one women (7%) were nulliparous, and 219 (73%) had history of pelvic surgery (150 had previous cesareans). Operating time, estimated blood loss, surgical techniques (Heaney, Pelosi, uterine morcellation), operative complications, conversion to laparoscopy or laparotomy, and length of hospital stay were recorded for each case. RESULTS: Vaginal hysterectomy was successful in 297 women (99%). Morcellation (hemisection, intramyometrial coring, myomectomy, and wedge resection) was done in 170 cases (56.7%). The mean operating time was 51 minutes (range 20-130 minutes), mean estimated blood loss was 180 mL (range 50-1050 mL), and mean length of hospitalization was 22 hours (range 16-72 hours). Four operative complications occurred (three cystotomies, one rectal laceration) and were repaired transvaginally. One woman needed a blood transfusion. Eleven urinary tract infections occurred. Two conversions to laparotomy and one conversion to laparoscopy were necessary. CONCLUSION: Vaginal hysterectomy is an effective and safe procedure for benign nonprolapsed uteri irrespective of nulliparity, previous pelvic surgery, or uterine enlargement. We question the true need for laparoscopy or laparotomy in this setting.

Ectopic pregnancy as an etiologic agent in appendicitis.

The association of ectopic pregnancy and acute appendicitis has seldom been discussed in literature. This report presents 2 patients who had simultaneous right tubal pregnancies and acute periappendicitis. The cases reported here suggest the possibility that an ectopic pregnancy can produce an inflammatory reaction of the appendix. Ectopic pregnancy as an etiological stimulus for acute appendicitis is discussed. The advisability of examining the appendix at the time of surgery for pelvic disease, and performing an appendectomy at the same time, if pathology of the appendix is suspected, is emphasized. The use of elective appendectomy in surgery for ectopic pregnancy is reviewed.

Use of dermal graft in the surgical repair of vaginal vault prolapse.

The use of dermal graft in the surgical repair of vaginal vault prolapse following hysterectomy is described. This tissue offers several advantages when compared with other materials frequently used. It is homologous, readily available, and easy to obtain; it has good strength and does not provoke foreign-body reactions or infections.

Galactorrhea associated with primary hypothyroidism. Report of two cases.

Two patients with primary hypothyroidism and galactorrhea are described. Elevated serum prolactin and thyroid-stimulating hormone levels were present. Following adequate thyroid hormone replacement restoration of clinical euthyroidism and cessation of galactorrhea occurred with a fall of both TSH and prolactin levels to normal.

Predictive value of human placental lactogen determinations in pregnancy.

The relation of human placental lactogen (hPL) levels to pregnancy outcome was studied in normal and preeclamptic pregnancies, hPL determinations were performed between 38 and 44 weeks of gestation, and the results were compared with birthweight and Apgar scores in three groups. The results of hPL determinations permitted prediction of intrauterine growth retardation in all except 2 patients. The value of hPL measurement as a screening test in pregnancy is noted.

Treatment of urinary stress incontinence. Use of dermal graft in the sling procedure.

Use of dermal graft for a urethral sling in treating urinary stress incontinence is described. This tissue has potential advantages of availability, strength, and freedom from side effects.

Renal carcinoma in pregnancy.

A gravid patient presented with gross hematuria in the last trimester of pregnancy but did not permit diagnostic measures. After delivery a large abdominal mass, which proved to be renal cell carcinoma, was found. Previously reported cases are reviewed, and the importance of adequate workup of hematuria during pregnancy is emphasized.

A diagnostic device for stress incontinence.

Many methods of evaluating anatomic deformity of the urethrovesical angle are available. A new diagnostic device has been developed to determine the degree of rotation of the urethral axis, thus differentiating between type I and type II deformities causing stress incontinence. Preliminary study in 62 patients indicates that the instrument is accurate, simple, and easily interpreted. The device also has the advantage of being easily constructed, disposable, and inexpensive.

Prophylactic antibiotics for cesarean section: comparison of high- and low-risk patients for endomyometritis.

The efficacy of ticarcillin in the prevention of post-cesarean section endomyometritis was studied in 259 women randomly given either the antibiotic or a placebo. The ticarcillin group received 6 g intravenously immediately after delivery. Then 22 of those patients were also given a second 3-g dose 6 to 8 hours after delivery. Among the 139 patients who received ticarcillin, endomyometritis developed in 44 (32%), as it did in 66 of 120 patients (55%) in the placebo group. These differences are highly significant (P = .002). Of the 259 patients in the study, 238 could be classified as to risk for endomyometritis developing. Among the 124 high-risk patients, 52 received a placebo and endomyometritis developed in 71%. Only 26 of the 72 high-risk patients who received ticarcillin (36%) were so infected. Among the low-risk patients, endomyometritis developed in 10 of 54 patients (18.5%) who received prophylaxis and in 24 of 60 patients who received placebo (40%). Ticarcillin appears to be effective in reducing the incidence of post-cesarean section endomyometritis in patients at high risk and in those at low risk. The number of pelvic examinations during labor was the most important single factor in the development of endomyometritis.

Pregnancy complicated by heroin addiction.

During a 5-year time span, 118 addicted women gave birth to viable infants. These patients were subject to an increased incidence of complicating medical problems as well as many obstetric problems leading to maternal or fetal risk. The obstetrician should be aware of the possibility of addiction and its effects on pregnancy, and when possible, appropriate management should be initiated. Intensive care of the neonate must be begun as soon as possible.

Laparoscopic-assisted transvaginal metroplasty for the treatment of bicornuate uterus: a case study.

OBJECTIVE: To introduce a combined laparovaginal metroplasty approach to the treatment of bicornuate uterus. DESIGN: Case report. SETTING: Private community hospital. PATIENT: A nulliparous patient with three recurrent spontaneous midtrimester abortions and a double uterus on hysterosalpingogram was evaluated laparoscopically. INTERVENTIONS: A laparoscopic-assisted transvaginal wedge metroplasty for the surgical correction of a symptomatic bicornuate uterus was performed. Intraoperative hysteroscopy also was used. MAIN OUTCOME MEASURES: Term pregnancy, uterine integrity. RESULTS: Hysteroscopic transillumination of the uterine horns delineated the uterine cavities while a laparoscopic wedge incision was initiated with a unipolar needle. The uterus was delivered through a posterior colpotomy, the wedge excision and uterine unification were completed transvaginally, the uterus was replaced into the pelvis, and the colpotomy was closed. The patient subsequently became pregnant, carried to term without complications, and delivered a healthy infant by cesarean section. The metroplasty scar was noted to be intact. CONCLUSIONS: Laparoscopic-assisted transvaginal metroplasty is a logical and useful minimally invasive alternative to laparotomy for the treatment of symptomatic bicornuate uterus and has potential utility for the treatment of complicated septate uterus and the correction of uterine perforation not amenable to laparoscopic suturing occurring during hysteroscopic septal resection.

Purification and characterization of a sperm-coating antigen from human seminal plasma.

A sperm-coating antigen has been purified from human seminal plasma by a combination of fractionation methods including ammonium sulfate precipitation, Sephadex G-100 gel filtration, and diethylaminoethyl cellulose ion-exchange chromatography. The purified antigen was demonstrated to be immunologically identical sperm-coating antigen, not derived from blood serum but having immunologically cross-relating antigens in milk and saliva, and a glycoprotein with a molecular weight of approximately 33,000. The purpose of purifying this antigen was discussed.