Low-dose aspirin and racial disparities in spontaneous preterm delivery in low-risk individuals.

BACKGROUND: Preterm birth is a leading cause of perinatal morbidity and mortality. There are significant racial disparities in the rates of preterm delivery in the United States, with Black individuals at disproportionately higher risk than their White counterparts. Although low-dose aspirin is currently under investigation for reducing the rates of preterm delivery, limited data are available on how the use of low-dose aspirin might affect racial and ethnic disparities in the rates of preterm delivery. OBJECTIVE: Our group and others have shown that low-dose aspirin decreases spontaneous preterm delivery in low-risk parturients. This study aimed to examine whether the relationship between low-dose aspirin and the risk of spontaneous preterm delivery is modified by race and ethnicity. STUDY DESIGN: This was a secondary analysis of a randomized clinical trial examining low-dose aspirin for preeclampsia prevention in low-risk nulliparous individuals. The parent trial defined low risk as the absence of preexisting hypertension or other medical comorbidities. Participants received 60-mg aspirin or placebo between 13 and 25 weeks of gestation. Here, multiple pregnancies, fetal anomalies, terminations or abortions at <20 weeks of gestation, and participants with previous miscarriages were excluded. Our exposure, race and ethnicity, was self-reported in the parent trial and categorized as non-Hispanic White, Hispanic, non-Hispanic Black, and other. The primary outcome was spontaneous preterm delivery at <34 weeks of gestation; the secondary outcomes included spontaneous preterm delivery at <37 weeks of gestation and all preterm deliveries at <34 and <37 weeks of gestation. Fit logistic regression models were used to examine how the use of low-dose aspirin modified the relationship between race and ethnicity and preterm delivery, adjusting for confounders. Furthermore, sensitivity analyses were performed to compare the rates of preterm delivery by race and ethnicity. RESULTS: Of note, 2528 of 3171 parent study participants were included in this analysis. Of the participants, 425 (16.8%) were White, 819 (32.4%) were Hispanic, 1265 (50%) were Black, and 19 (0.8%) were other. The baseline characteristics differed among racial and ethnic groups, including maternal age, body mass index, education level, marital status, tobacco and alcohol use, and pregnancy loss. The rate of spontaneous preterm delivery at <34 weeks of gestation was significantly higher in Black participants (2.8%) than in White (1.2%) and Hispanic (1.2%) participants (P=.04). Logistical regression analysis showed that Black race was no longer an independent risk factor for spontaneous preterm delivery at <34 weeks of gestation when controlling for low-dose aspirin (adjusted odds ratio, 1.71; 95% confidence interval, 0.67-4.40). A similar pattern was found for spontaneous preterm delivery at <37 weeks of gestation and preterm delivery at <34 and <37 weeks of gestation. In our sensitivity analyses, spontaneous preterm delivery at <34 weeks of gestation differed by race and ethnicity in the placebo group (P=.01) but did not differ in the low-dose aspirin group (P=.90). CONCLUSION: The use of low-dose aspirin mitigated racial disparities in spontaneous preterm delivery at <34 weeks of gestation. Additional investigation is warranted to assess the reproducibility of our findings.

Race and neonatal respiratory morbidity in the late preterm period.

BACKGROUND: Prematurity is one of the leading causes of perinatal morbidity and mortality. Some studies suggest that respiratory disease may differ by race in early preterm infants. However, the role of race in late preterm neonatal morbidity is not yet established. OBJECTIVE: The objective of our study was to determine whether neonatal respiratory morbidity differs by race in neonates born late preterm. STUDY DESIGN: This was a secondary analysis of a randomized trial of women at high risk for late preterm delivery (Antenatal Late Preterm Steroids). Our study was limited to women with nonanomalous, singleton gestations, delivering between 34+0 to 36+6 weeks. Women were categorized into 4 groups by race: Black, White, Asian, or other/mixed. The primary outcome was a neonatal composite of treatment in the first 72 hours (continuous positive airway pressure or high-flow nasal cannula >2 hours, oxygen >4 hours, extracorporeal membrane oxygenation or mechanical ventilation) or stillbirth or neonatal death before 72 hours. The secondary outcomes included severe respiratory morbidity (the primary outcome extending continuous positive airway pressure or high-flow nasal cannula to >12 continuous hours and oxygen to at least 24 continuous hours), respiratory distress syndrome, transient tachypnea of the newborn, apnea, neonatal intensive care unit admission, bronchopulmonary dysplasia, and surfactant administration. The primary and secondary outcomes were assessed in the active (steroid) and placebo groups separately. We fit a logistic regression model to adjust for confounders related to respiratory morbidity. RESULTS: Of a total of 2331 included women, 26.9% (n=627) were Black/African American, 57.1% (n=1333) White, 3.56% (n=83) Asian, and 12.36% (n=288) were other/mixed. In the placebo group, the rate of the primary outcome was significantly higher in Whites (18.6%) and Asians (22.8%) compared with the African American/Black group (12.3%) (P=.03). Adjusting for confounders, the primary outcome was not significant between the groups. The primary predictor for respiratory morbidity was a prior pregnancy with neonatal respiratory morbidity. Findings were similar in the steroid group, but severe respiratory morbidity was less common in Black infants compared with White infants (adjusted odds ratio, 0.45; 95% confidence interval, 0.24-0.83). However, a prior pregnancy with neonatal respiratory complications was no longer associated with respiratory morbidity after receipt of betamethasone. CONCLUSION: Late preterm respiratory morbidity was similar between racial groups. Although a history of pregnancy with previous neonatal respiratory disease is the strongest risk factor for recurrence, this risk factor is mitigated by the receipt of steroids.

Low-dose aspirin is associated with reduced spontaneous preterm birth in nulliparous women.

BACKGROUND: Preterm birth is one of the leading causes of perinatal morbidity and mortality. Clinical data suggest that low-dose aspirin may decrease the rate of overall preterm birth, but investigators have speculated that this is likely due to a decrease in medically indicated preterm birth through its effect on the incidence of preeclampsia and other placental disease. We hypothesized that low-dose aspirin may also have an impact on the mechanism of spontaneous preterm labor. OBJECTIVE: Our objective was to determine whether low-dose aspirin reduces the rate of spontaneous preterm birth in nulliparous women without medical comorbidities. STUDY DESIGN: This is a secondary analysis of a randomized, placebo-controlled trial of low-dose aspirin for the prevention of preeclampsia in healthy, low-risk, nulliparous women. Low-risk women were defined by the absence of hypertension, renal disease, diabetes, other endocrine disorders, seizures, heart disease, or collagen vascular disease. Our study was limited to singleton, nonanomalous gestations. Women were eligible if they had prior pregnancy terminations but not prior spontaneous pregnancy loss <20 weeks. Current pregnancies that resulted in a loss or termination <20 weeks or antepartum stillbirth or had missing follow-up data were excluded. The treatment intervention was 60 mg of aspirin, initiated at 13-25 weeks' gestation or matching placebo. The primary outcome was spontaneous preterm birth <34 weeks' gestation. Secondary outcomes included spontaneous preterm birth <37 weeks and overall preterm birth <37 and <34 weeks. Baseline demographics and primary and secondary outcomes were compared between treatment groups. A logistic regression model was used to adjust for confounders related to spontaneous preterm birth. RESULTS: Of 2543 included women, 1262 (49.6%) received low-dose aspirin and 1281 (50.4%) placebo. Baseline characteristics were similar between groups, except for marital status. The rate of spontaneous preterm birth <34 weeks was 1.03% (n = 13) and 2.34% (n = 30) in the low-dose aspirin and placebo group, respectively (odds ratio, 0.43, 95% confidence interval, 0.26-0.84). Additionally, the rate of spontaneous preterm birth <37 weeks was 6.58% (n = 83) in the low-dose aspirin group and 7.03% (n = 90) in the placebo group (odds ratio, 0.97, 95% confidence interval, 0.71-1.33), and the rate of overall preterm birth <37 weeks was 7.84% (n = 99) in the low-dose aspirin group and 8.2% (n = 105) in the placebo group (odds ratio, 0.97, 95% confidence interval, 0.72-1.31). After adjustment for variables that were clinically relevant or statistically significant, including body mass index, race, tobacco use, marital status, and education level, there was a significant reduction in spontaneous preterm birth <34 weeks in the low-dose aspirin group (adjusted odds ratio, 0.46, 95% confidence interval, 0.23-0.89). The rates of overall preterm birth <34 and <37 weeks and spontaneous preterm birth <37 weeks were similar in women who received low-dose aspirin compared with placebo. CONCLUSION: Low-dose aspirin is associated with a substantial decrease in spontaneous preterm birth <34 weeks in healthy nulliparous women without comorbidities. These findings suggest a new therapeutic option for preterm birth prevention that requires further study.

Ovarian cancer laparoscopic hysterectomy and staging in a patient with history of intraperitoneal renal transplant.

OBJECTIVE: Ovarian cancer laparoscopic staging of patient with intraperitoneal renal transplant. METHODS: 43-year-old female with intra-peritoneal renal transplant was referred status post laparoscopic bilateral ovarian cystectomies. The pathology report revealed serous adenocarcinoma with clear cell and papillary features of ovaries and endometrium. She was asymptomatic with benign examination. PET/CT of chest/abdomen/pelvis showed area of metabolic activity in left ovary and right common iliac pelvic lymph nodes. RESULTS: During laparoscopic staging [1], the intraperitoneal kidney transplant was firmly adhered to the uterus, right pelvic sidewall and adnexa. Right pelvic lymph node debulking was performed but not paraaortic lymph node dissection because of increased morbidity of this case. The final pathology showed ovarian serous adenocarcinoma with clear cell features, without involvement of endometrium, negative lymph nodes and peritoneal washings. We believe that the intrauterine pathological finding during the first surgery was "drop lesion" from the ovary to the uterine cavity. Thus, the final stage assigned was IC1, secondary to ovarian cyst rupture at the initial surgery. She received six cycles of intravenous Carboplatin and Taxol. There is no evidence of recurrence in nine-month follow up. CONCLUSION: The incidence of malignancies is increasing in cases of renal transplant secondary to the age of patients and the immunosuppressive therapy [2,3]. Laparoscopic surgical treatment for gynecologic malignancies can be challenging due to location of transplanted kidney in the pelvis [4]. We present a rare case of laparoscopic ovarian cancer staging with intraperitoneal renal transplant, which can be safely performed in hands of a skilled laparoscopic surgeon.

Management of infected urethral diverticulum with urethral dilation.

BACKGROUND: Urethral diverticula are rare but underdiagnosed entities that may cause a variety of urinary and pelvic symptoms in women. Management can be very challenging, especially in cases of chronic infection. CASE: A 69-year-old gravida 4, para 2 woman with a history of type 2 diabetes and hypothyroidism presented with long history of a painful midline 3-cm suburethral cystic mass, recurrent urinary tract infections, dysuria, dyspareunia, and incomplete voiding. The diagnosis was consistent with an infected urethral diverticulum unresponsive to multiple courses of oral antibiotics. Given the patient's comorbidities and the persistence of infection of the diverticulum, conservative treatment with urethral dilation was performed before surgical treatment. Urethral dilation successfully alleviated the patient's symptoms; the surgical treatment was not ultimately required, and the patient continues to be completely asymptomatic well over 17 months later. CONCLUSIONS: We present a unique case of infected urethral diverticulum, which was conservatively treated with dilatation and resulted in resolution of all symptoms, and there is no need for further surgical management.

Rare case of neglected pessary presenting with concealed vaginal hemorrhage.

BACKGROUND: Vaginal pessaries are commonly used for management of pelvic organ prolapse. Severe complications can occur in neglected cases. CASE: A 91-year old woman with significant comorbidities presented with large concealed vaginal bleeding and history of vaginal pessary placement 14 years before. On examination, an impacted Gellhorn pessary in the vagina was noted with some spotting. Serum blood tests revealed severe anemia and renal insufficiency. An abdominal and pelvic computed tomographic scan confirmed a Gellhorn pessary and a large vaginal accumulation of blood superior to impaction. The pessary was surgically removed vaginally under anesthesia. Recovery was uneventful, and the patient was discharged 1 week later. CONCLUSION: Our case underlines the need of follow-up and compliance after pessary placement for early detection of complications.

Maternal pravastatin prevents altered fetal brain development in a preeclamptic CD-1 mouse model.

OBJECTIVE: Using an animal model, we have previously shown that preeclampsia results in long-term adverse neuromotor outcomes in the offspring, and this phenotype was prevented by antenatal treatment with pravastatin. This study aims to localize the altered neuromotor programming in this animal model and to evaluate the role of pravastatin in its prevention. MATERIALS AND METHODS: For the preeclampsia model, pregnant CD-1 mice were randomly allocated to injection of adenovirus carrying sFlt-1 or its control virus carrying mFc into the tail vein. Thereafter they received pravastatin (sFlt-1-pra "experimental group") or water (sFlt-1 "positive control") until weaning. The mFc group ("negative control") received water. Offspring at 6 months of age were sacrificed, and whole brains underwent magnetic resonance imaging (MRI). MRIs were performed using an 11.7 Tesla vertical bore MRI scanner. T2 weighted images were acquired to evaluate the volumes of 28 regions of interest, including areas involved in adaptation and motor, spatial and sensory function. Cytochemistry and cell quantification was performed using neuron-specific Nissl stain. One-way ANOVA with multiple comparison testing was used for statistical analysis. RESULTS: Compared with control offspring, male sFlt-1 offspring have decreased volumes in the fimbria, periaquaductal gray, stria medullaris, and ventricles and increased volumes in the lateral globus pallidus and neocortex; however, female sFlt-1 offspring showed increased volumes in the ventricles, stria medullaris, and fasciculus retroflexus and decreased volumes in the inferior colliculus, thalamus, and lateral globus pallidus. Neuronal quantification via Nissl staining exhibited decreased cell counts in sFlt-1 offspring neocortex, more pronounced in males. Prenatal pravastatin treatment prevented these changes. CONCLUSION: Preeclampsia alters brain development in sex-specific patterns, and prenatal pravastatin therapy prevents altered neuroanatomic programming in this animal model.

Assessment of angiogenic markers and female sex hormone receptors in pregnancy tumor of the gingiva.

PURPOSE: Oral pregnancy tumors (OPTs) arise on the inflamed gingiva of women after the first trimester of pregnancy. The expression of angiogenic markers and female hormone receptors was assessed. MATERIALS AND METHODS: Immunohistochemistry was used to analyze the expression of estrogen and progesterone receptors and the expression of angiogenic factors, such as vascular endothelial growth factor (VEGF) and its receptor, fibroblast growth factor (FGF), and hypoxia inducible factors 1α and 3α (HIF1α and HIF3α). Experimental groups included 9 OPTs, 10 oral pyogenic granulomas from nonpregnant women of the same age, and 9 oral pyogenic granulomas from postmenopausal women. RESULTS: VEGF expression in stromal histiocytes and endothelial cells of small vessels was positively correlated in the OPT group (P < .05 by χ(2) test). VEGF receptor also was overexpressed in stromal histiocytes and endothelial cells of OPTs compared with oral pyogenic granulomas from nonpregnant and postmenopausal women (P < .005 by χ(2) test). No correlation was detected among estrogen and progesterone receptors, FGF and HIF1α and HIF3α (ER and PgR respectively) in the 3 experimental groups. CONCLUSIONS: VEGF-associated angiogenesis is most likely involved in the pathogenesis of the lesion. These results imply that local inhibition of VEGF activity could be an adjuvant therapeutic approach for OPTs to control hemorrhage, which can be massive at the surgical excision of such lesions during pregnancy.

Aortocaval fistula formation due to ruptured abdominal aortic aneurysms: a 12-year series.

This study reports on the frequency and management of aortocaval fistulas (ACFs) in our department between 1998 and 2009. Overall frequency of ACFs among ruptured abdominal aortic aneurysms was 5.5%. Patients presented with low back pain (92.8%), abdominal tenderness (78.6%), hemorrhagic shock (28.6%), congestive heart failure (21.4%), dyspnea (42.8%), and palpitations (57.1%). The most reliable clinical sign was the presence of palpable pulsating abdominal mass (92.8%). Other clinical findings included increased central venous pressure (21.4%), lower extremity edema (71.4%), hematuria (21.4%), and scrotal edema (14.3%). Diagnosis was established preoperatively in 85.7% and intraoperatively in 14.3% of cases. Surgery was successful in promptly improving clinical signs and symptoms. Mortality rate was 7.1%. After a mean follow-up of 18.5 months, all surviving patients remained free from complications. In conclusion, ACFs represent a life-threatening emergency for vascular surgeons but can be successfully managed.

Insertion of central venous catheters for hemodialysis using angiographic techniques in patients with previous multiple catheterizations.

INTRODUCTION: Central venous catheter placement is an effective alternative vascular access for dialysis in patients with chronic renal failure. The purpose of this study was to evaluate the insertion of central venous catheters for hemodialysis using angiographic techniques in patients with previous multiple catheterizations in terms of efficacy of the procedure and early complications. MATERIALS AND METHODS: Between 2008 and 2010, the vascular access team of our hospital placed 409 central venous catheters in patients with chronic renal failure. The procedure was performed using the Seldinger blind technique. In 18 (4.4%) cases it was impossible to advance the guidewire, and so the patients were transported to the angiography suite. RESULTS: Using the angiographic technique, the guidewire was advanced in order to position the central venous catheter. The latter was inserted into the subclavian vein in 12 (66.6%) cases, into the internal jugular vein in 4 (22.2%) and into the femoral vein in 2 (11.1%) cases. There was only one complicated case with severe arrhythmia in 1 (5.5%) patient. CONCLUSION: Our results suggest that insertion of central venous catheters using angiographic techniques in hemodialysis patients with previous multiple catheterizations is a safe and effective procedure with few complications and high success rates.

Traumatic ulcerative granuloma with stromal eosinophilia: report of a case and literature review.

Traumatic eosinophilic granuloma with stromal eosinophilia is a rare entity that affects the oral mucosa and has a controversial etiologic pathogenesis. Histologically, these lesions are characterized by a dense and deeply infiltrative lymphoproliferation showing epitheliotropic characteristics and massive eosinophilia. Frequently, a population of mitotically active, atypical mononuclear cells can be noted. This report describes a case of traumatic eosinophilic granuloma with stromal eosinophilia in the floor of the mouth of an 88-year-old man. The phenotypic and genotypic profiles of the inflammatory infiltrate and large atypical mononuclear cells, using immunohistochemical and polymerase chain reaction-based molecular analysis, were analyzed.

Characteristics of patients presenting to the vascular emergency department of a tertiary care hospital: a 2-year study.

BACKGROUND: The structure of health care in Greece is receiving increased attention to improve its cost-effectiveness. We sought to examine the epidemiological characteristics of patients presenting to the vascular emergency department of a Greek tertiary care hospital during a 2-year period. We studied all patients presenting to the emergency department of vascular surgery at Red Cross Hospital, Athens, Greece between 1st January 2009 and 31st December 2010. RESULTS: Overall, 2452 (49.4%) out of 4961 patients suffered from pathologies that should have been treated in primary health care. Only 2509 (50.6%) needed vascular surgical intervention. CONCLUSIONS: The emergency department of vascular surgery in a Greek tertiary care hospital has to treat a remarkably high percentage of patients suitable for the primary health care level. These results suggest that an improvement in the structure of health care is needed in Greece.

Serum leptin levels in patients undergoing carotid endarterectomy: a pilot study.

INTRODUCTION: Elevated serum leptin levels are associated with cardiovascular events. We investigated the role of serum leptin in patients undergoing carotid endarterectomy (CEA). METHODS: A total of 74 patients (55 men; 38 symptomatic and 36 asymptomatic; mean age 66.9 +/- 8.2 years) undergoing CEA for >70% carotid artery stenosis were enrolled. RESULTS: Serum leptin levels were lower in symptomatic compared with asymptomatic patients (7.1 +/- 1.3 vs 14.4 +/- 4.7 ng/dL; P < .001). Interleukin-6 (IL-6) levels were higher in symptomatic compared with asymptomatic patients (4.3 +/- 1.7 vs 3.3 +/- 1.1 pg/dL; P = .017). Symptomatic patients had more intense macrophage accumulation (0.7% +/- 0.1% vs 0.3% +/- 0.1%; P < .001). Serum leptin and serum IL-6 levels were independently associated with the presence of symptoms in multivariate analysis. CONCLUSION: Serum leptin levels were decreased in symptomatic carotid artery disease. This finding requires further investigation in larger studies.