Recent attempted and actual weight change in relation to pregnancy loss: a prospective cohort study.

OBJECTIVE: To assess weight change and attempted weight loss during the 12-18 months before spontaneous conception in relation to the risk of pregnancy loss. DESIGN: Prospective cohort study. SETTING: United States, 2007-2011. METHODS: Women (n = 629) who were attempting pregnancy reported at baseline any weight loss attempts over the past 12 months, and their minimum and maximum weights during that time. Follow up lasted one to six menstrual cycles and throughout pregnancy. Using bodyweight measured at 4 weeks' gestation, participants were categorised as having weight loss ≥5%, weight gain ≥5%, both, or neither, over the previous 12-18 months. Log-binomial models adjusted for potential confounders. MAIN OUTCOME MEASURES: Risk ratio (RR) and 95% confidence interval (CI) of pregnancy loss. RESULTS: Attempted weight loss was reported by 44% of women and actual weight loss by 11%, but neither was consistently associated with pregnancy loss. The RR for recent weight gain ≥5% was 1.65 (CI 1.09, 2.49). CONCLUSIONS: Weight gain over the period spanning 12-18 months pre-conception to 4 weeks' gestation may increase the risk of pregnancy loss among fertile women with prior pregnancy losses. Attempted and actual weight loss were not associated with pregnancy loss; however, replication is needed from larger studies with data on particular weight-loss methods. TWEETABLE ABSTRACT: Recent weight gain before and around the time of conception may increase the risk of pregnancy loss.

Dietary intake and major food sources of polyphenols in people with type 2 diabetes: The TOSCA.IT Study.

PURPOSE: Proper evaluation of polyphenols intake at the population level is a necessary step in order to establish possible associations with health outcomes. Available data are limited, and so far no study has been performed in people with diabetes. The aim of this work was to document the intake of polyphenols and their major food sources in a cohort of people with type 2 diabetes and in socio-demographic subgroups. METHODS: We studied 2573 men and women aged 50-75 years. Among others, anthropometry was measured by standard protocol and dietary habits were investigated by food frequency questionnaire (EPIC). The intake of polyphenols was evaluated using US Department of Agriculture and Phenol-Explorer databases. RESULTS: The mean total polyphenol intake was 683.3 ± 5.8 mg/day. Non-alcoholic beverages represented the main food source of dietary polyphenols and provided 35.5% of total polyphenol intake, followed by fruits (23.0%), alcoholic beverages (14.0%), vegetables (12.4%), cereal products and tubers (4.6%), legumes (3.7%) and oils (2.1%); chocolate, cakes and nuts are negligible sources of polyphenols in this cohort. The two most important polyphenol classes contributing to the total intake were flavonoids (47.5%) and phenolic acids (47.4%). Polyphenol intake increased with age and education level and decreased with BMI; furthermore, in the northern regions of Italy, the polyphenol intake was slightly, but significantly higher than in the central or southern regions. CONCLUSIONS: The study documents for the first time the intake of polyphenols and their main food sources in people with diabetes using validated and complete databases of the polyphenol content of food. Compared with published data, collected in people without diabetes, these results suggest a lower intake and a different pattern of intake in people with diabetes.

Incidence and Risk Factors of Developing Post-operative Delirium Among Elderly Patients in a Tertiary Care Hospital: A Retrospective Chart Review.

Introduction Delirium is an acute and fluctuating decline in attention and cognition caused by reversible neural disruption. Post-operative delirium (POD) may happen 10 minutes after anesthesia administration up to discharge. POD has been associated with increased days of mechanical ventilation, increased patients' functional decline, prolonged intensive care unit (ICU) stay, and prolonged hospital length of stay, which can lead to nosocomial complications, further investigations, and increased treatment costs. In this study, we aim to determine the prevalence of POD and identify demographic or surgical variables associated with POD. Materials and methods This retrospective cross-sectional study was conducted at the National Guard Health Affairs Hospital (NGHA), a teaching tertiary care center in Riyadh, Kingdom of Saudi Arabia. The study included all patients older than 65 who developed POD from January 2017 to January 2023 and a control group of the same time window. The data were analyzed using custom Python code. Results The study included 108 patients, 72 of whom were male patients. General anesthesia was most used compared to other anesthesia techniques (79.630%). Patients with hypertension (HTN) and diabetes mellitus (DM) each account for 75 cases. Elective surgeries account for 86.111% of cases. Our analysis showed a significant association between POD and advanced age, male gender, DM, HTN, congestive heart failure (CHF), and chronic kidney disease (CKD).  Conclusion With our study, we hope to aid the process of better understanding POD to help healthcare providers identify high-risk patients, implement preventative measures, and enhance patient safety and satisfaction.

Hypertension and risk of uterine leiomyomata in US black women.

BACKGROUND: Previous studies have found a positive association between hypertension and risk of hysterectomy-confirmed uterine leiomyomata (UL). The association of hypertension with UL confirmed by ultrasound or other surgery is less clear. METHODS: The present study evaluated the association of hypertension with UL incidence according to confirmation method (hysterectomy, other surgery or ultrasound) in the Black Women's Health Study, 1997-2007. We collected prospective data every 2 years on physician-diagnosed hypertension and UL in 22 530 premenopausal women. Validation sub-studies confirmed 99 and 96% of hypertension and UL self-reported diagnoses, respectively. Cox regression was used to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) for the association of hypertension and UL, adjusting for potential confounders. RESULTS: During 172 162 person-years of follow-up, there were 6447 incident cases of UL confirmed by ultrasound (n = 5111), hysterectomy (n = 670) or other surgery (n = 666). Treated hypertension was associated with UL confirmed by hysterectomy (IRR = 1.32, 95% CI: 1.06, 1.63), but it was not associated with UL confirmed by ultrasound (IRR = 1.05, 95% CI: 0.96, 1.16) or other surgery (IRR = 1.13, 95% CI: 0.88, 1.46). CONCLUSIONS: Treated hypertension was associated with UL confirmed by hysterectomy, but not UL confirmed by other methods (other surgery or ultrasound). These data suggest it is premature to conclude that hypertension is related to an increased risk of UL. Additional studies are needed to assess whether the association with hysterectomy-confirmed UL can be explained by other sources of bias, such as patient or physician preferences for specific types of medical care.

Preoperative systemic chemotherapy followed by adjuvant postoperative intraperitoneal therapy for gastric cancer: a University of Southern California pilot program.

PURPOSE: A clinical trial for patients with gastric cancer amenable to curative resection was undertaken to determine feasibility and response to preoperative systemic chemotherapy followed by postoperative intraperitoneal (IP) chemotherapy. METHODS AND MATERIALS: Thirty-eight patients with resectable gastric tumor received two cycles of protracted intravenous (IV)-infusion fluorouracil (5FU), 200 mg/m2/d, for 3 weeks with weekly IV leucovorin 20 mg/m2 and IV cisplatin 100 mg/m2 days 1 and 29. Resection of the gastric tumor followed within 3 weeks of completion of systemic chemotherapy. Those who had all visible tumor removed with clear margins received two cycles of IP floxuridine 3,000 mg (total dose) per day for 3 days and IP cisplatin 200 mg/m2 with IV sodium thiosulfate on the fourth day of IP therapy. RESULTS: Thirty-seven of 38 patients (97%) received two cycles of systemic chemotherapy. Thirty-five of 38 patients (92%) underwent laparotomy for gastric tumor resection. Thirty-three patients (87%) had gastric resections performed; 29 (76%) had all visible tumor removed with microscopically negative margins. No operative mortality was encountered. Twenty-six patients (68%) received IP treatment. IV neoadjuvant treatment was well tolerated and resulted in 68% of the patients reporting improvement in abdominal pain, 45% objective remissions by computed tomography (CT), 38% objective remissions by gastroscopy and biopsy, and 8% had complete surgical pathologic response. Neutropenic sepsis during the IP treatment phase contributed to the only treatment-related death. Four of 29 completely resected patients (14%) have had tumor recurrence. The median follow-up time of patients remaining alive is now 19 months. The median survival for 38 patients entered onto this protocol has not been reached at 17+ months. CONCLUSION: This novel approach to the treatment of adenocarcinoma of the stomach is feasible. The neoadjuvant systemic therapy results in significant primary tumor regression. The determination of whether systemic or IP components of the program contribute to decreased recurrence or increased survival awaits a prospectively randomized clinical trial.

Pylethrombosis. Serendipitous radiologic diagnosis.

Pylethrombosis is thrombosis of the portal vein or any of its branches. Five cases have been serendipitously detected, four by computed tomography and one by ultrasonography. Two patients had abdominal sepsis. A third patient had apparent acute cholecystitis with choledocholithiasis. The last two patients had a hypercoagulable state, mesenteric venous thrombosis, and enteric infarction that required resection. The newer diagnostic modalities of computed tomography and ultrasound may document unsuspected pylethrombosis. Surgery may be required because of signs of peritonitis, enteric ischemia, or unresolved sepsis. Anticoagulation is indicated for acute thrombosis of the portal or superior mesenteric veins to prevent further extension and enteric ischemia.

The role of anticoagulation in pylephlebitis.

BACKGROUND: Pylephlebitis may complicate any intra-abdominal infection and carries a high mortality rate. Acute cases are usually anticoagulated to prevent thrombus extension and enteric ischemia; however, the role of anticoagulation has not been clearly defined. METHODS: Over a 3-year period, pylephlebitis was diagnosed in 44 patients with portal vein thrombosis on computed tomography scan with fever, leukocytosis, and/or positive blood cultures. The charts were reviewed for etiology, extent of venous thrombosis, and method and results of treatment. RESULTS: Eighteen patients were hypercoagulable, due to clotting factor deficiencies (6), malignancy (8), or AIDS (4). Fifteen patients had mesenteric vein involvement. Thirty-two patients were not anticoagulated, and 5 died (3 with hypercoagulable states and 2 with normal clotting function). Twelve patients were anticoagulated, and none developed subsequent bowel infarction or died. CONCLUSION: Patients with pylephlebitis and a hypercoagulable state due to neoplasms or clotting factor deficiencies should be anticoagulated. Patients with normal clotting function and mesenteric vein involvement may also benefit. We believe anticoagulation in patients with thrombus isolated to the portal vein and normal clotting function may be unnecessary.

Around-the-clock attending radiology coverage is essential to avoid mistakes in the care of trauma patients.

Financial constraints due to increasing operating cost and decreased reimbursement do not allow many hospitals to maintain coverage by attending radiologists around the clock (CARAC). Preliminary film readings by radiology trainees may be inaccurate. In trauma, decisions are made fast and are often based on these preliminary readings. To examine whether there are significant discrepancies between preliminary readings (PRs) and final readings (FRs) of CT scans of trauma patients we prospectively recorded PRs (done immediately by radiology residents) and FRs (done the following working day by radiology attendings) over a period of 6 months for trauma CT scans done between 5 PM and 7 AM on weekdays or weekends. A discrepancy was classified as significant if a change in management was instituted after FR. In 42 of 383 (11%) trauma patients there was a discrepancy between PR and FR. Patients with discrepancies had a higher Injury Severity Score, higher incidence of penetrating trauma, longer hospital stay, higher hospital charges, and higher mortality than patients without any discrepancy. Most of the discrepancies were found on abdominal CT scans. The lower the level of radiology resident doing the PR the higher the likelihood of a discrepancy. In 20 patients (5%) a significant discrepancy was found. We conclude that the absence of CARAC results in inaccurate FRs risking optimal trauma patient care. The institutional savings realized by avoiding CARAC may be offset by the cost of additional care provided to patients who have delayed diagnosis and treatment due to the lack of it.

Myomatous erythrocytosis syndrome: a case report.

We report the case of a 36-year-old woman with erythrocytosis due to ectopic erythropoietin production by a very large uterine leiomyoma. Awareness of this uncommon condition is important so that the correct diagnosis can be suggested prior to surgery and radical resection can be avoided.

HIV infection: analysis in 259 consecutive patients with abnormal abdominal CT findings.

PURPOSE: To evaluate abdominal computed tomographic (CT) findings in patients with human immunodeficiency virus (HIV) infection. MATERIALS AND METHODS: CT scans with abnormal findings in 259 patients (247 men, 12 women; age range, 21-60 years) with HIV infection were analyzed. Diagnoses were mycobacterial infection (n = 87), lymphoproliferative disease (n = 63), Kaposi sarcoma (n = 17), fungal infection (n = 17), hepatocellular disease (n = 13), Pneumocystis carinii infection (n = 8), other disorders (n = 39), or unknown (n = 30). RESULTS: Abnormal findings included lymph-node enlargement (n = 159), hepatomegaly (n = 100), splenomegaly (n = 62), gastrointestinal mass or wall thickening (n = 61), and low-attenuation lesions in the liver (n = 50) or spleen (n = 55). Diagnoses thought to account for CT findings were made (n = 229) or suspected (n = 18) in 247 (95%) of the 259 patients. CONCLUSION: In most patients with HIV infection, abnormal abdominal CT findings are due to a second disease. Even relatively nonspecific findings should not be ascribed to HIV infection and should prompt a search for an opportunistic infection or neoplasm.

Acute mesenteric and retroperitoneal lymphadenitis in systemic lupus erythematosus: case report.

In a young woman with clinical evidence of acute cutaneous, musculoskeletal, and neurologic manifestations of systemic lupus erythematosus, computed tomography (CT) showed enlarged, centrally hypoattenuating mesenteric and retroperitoneal lymph nodes. After treatment with steroids, the CT appearance of the lymph nodes returned to normal. The differential diagnosis of lymph nodes with central hypoattenuation includes Mycobacterium tuberculosis infection, metastatic disease (especially squamous cell carcinoma and germ cell tumor), Whipple's disease, and celiac disease in addition to lupus lymphadenitis.

Malignant epithelioid renal angiomyolipoma in a patient with tuberous sclerosis.

A21-year-old man with a history of tuberous sclerosis and hematuria was found to have multiple renal angiomyolipomas and a highly malignant epithelioid renal angiomyolipoma. Radiologic and pathologic findings are described.

Carney complex: report of three cases.

The authors report three patients with features of the Carney complex: cardiac myxomas (n = 2), multicentric (n = 1) or recurrent (n = 1); pigmented skin lesions (n = 2); cutaneous myxomas (n = 2); melanotic schwannoma (n = 2); and sonographic evidence of multicentric, large cell, calcifying Sertoli cell tumors of the testes (n = 1). The initial component of the complex was cutaneous myxoma (n = 1), cardiac myxoma (n = 1), or psammomatous melanotic schwannoma (n = 1). Two patients died of metastatic schwannoma.

Generalized juvenile polyposis with carcinoma.

Generalized juvenile polyposis usually is not associated with an increased risk for gastrointestinal carcinoma. A subgroup of patients, however, have juvenile polyps with adenomatous features. A case report of juvenile polyposis, together with adenocarcinoma of the colon and review of the literature, are presented to emphasize the potential for malignancy in this subgroup of patients and to guide appropriate evaluation.

Two pretreatment regimens for high-risk patients receiving radiographic contrast media.

The risk of anaphylactoid reaction (AR) developing from radiographic contrast media in patients who previously have had an AR to radiographic contrast media ranges from 17% to 60%. Pretreatment with prednisone plus diphenhydramine or prednisone and diphenhydramine plus ephedrine decreased the reaction rate to 9.0% and 3.1%, respectively, during 657 procedures in 563 patients. No deaths occurred, and only three episodes of transient hypotension developed, one of which was treated with epinephrine. Pretreatment consisted of prednisone, 50 mg, 13 hr, 7 hr, and 1 hr before the procedure and diphenhydramine, 50 mg, 1 hr and or ephedrine, 25 mg, 1 hr before the procedure. The addition of ephedrine provided a statistically significant reduction in reaction in 192 procedures (chi 2 = 5.4996, p = 0.019). In 138 procedures in patients whose initial AR was considered serious, pretreatment was as effective as for patients with histories of mild to moderate reactions. Emergency equipment should be available for all procedures.

Antibodies to purified protein derivative in different immunoglobulin classes in the diagnosis of tuberculosis in man.

The sera of patients with active tuberculosis (TB) and sera from control groups were assayed for IgG, IgA, secretory IgA, IgM and IgE antibody activity to purified protein derivative (PPD) using the enzyme-linked immunosorbent assay. Patients with active TB clearly had higher levels of IgG antibody activity to PPD antigen than did healthy patients who were skin test positive or negative. There was a clear separation between the diseased and healthy groups. Similar, but not as marked increases were seen in IgA and secretory IgA antibody activity in diseased patients. No correlation between the presence of disease and antibody levels were found with IgM, and no IgE antibodies were found. The method presented is a rapid reproducible assay using commercially available materials, and may offer a clinically useful test for the diagnosis of TB.

Splenic involvement in endemic (murine) typhus: CT findings.

Murine typhus is a rickettsial infection that remains endemic in parts of Texas and California. Clinical manifestations of the infection are due to vasculitis. In a patient who acquired the infection in the United States, computed tomography demonstrated intrasplenic pseudoaneurysms, infarcts, and hemorrhage.

Allergic reactions to measles (rubeola) vaccine in patients hypersensitive to egg protein.

We evaluated two children with allergy to egg-white protein (ovalbumin) who had generalized urticaria, angioedema, and respiratory difficulty after immunization with live rubeola vaccine. In both patients, serum IgE reactive with ovalbumin-related antigens in the vaccine was demonstrated. Subsequent evaluation of 24 children with ovalbumin allergy revealed that those who had positive ovalbumin skin tests, but no clinical reaction to egg white, were skin test negative on prick and intradermal testing with measles vaccine and were safely immunized. They had no detectable IgE directed against the rubeola vaccine, although IgE directed at ovalbumin was present. Six patients who had severe allergic hypersensitivity reactions on exposure to ovalbumin had IgE antimeasles vaccine antibody and had positive reactions after intracutaneous or intradermal testing with the vaccine. These patients were safely immunized with increasing volumes (0.05 ml increments every 20 minutes) of measles vaccine to receive the full dose. These studies suggest that children with severe allergic hypersensitivity to egg white should be screened with an intracutaneous test prior to immunization with measles vaccine; however, children who have positive skin tests but no clinical reaction to ovalbumin exposure are at minimal risk for hypersensitivity reactions to measles immunization, as previously reported.

Blue rubber bleb nevus syndrome presenting with recurrences.

An unusual patient with blue rubber bleb nevus syndrome is presented. At birth a single abdominal wall hemangioma was noted, and over a 21-year follow-up the full syndrome developed, including many cutaneous and intestinal lesions and anemia. Our long-term follow-up of this patient allows an understanding of the natural history of this condition, especially regarding recurrence of lesions after excision.