Prognostic role and characteristics of the indeterminate response in differentiated thyroid cancer: a systematic review.

PURPOSE: The management of differentiated thyroid cancer (DTC) is actually based on a dynamic risk stratification based on classes of response to the therapy. Indeterminate response (IR) includes a heterogeneous group of patients with different characteristics, particularly different Tg and AbTg levels and/or imaging findings. The aim of systematic review (SR) is to evaluate the prognosis, diagnostic findings and other characteristics of patients in the IR class. METHODS: A wide literature search in the Scopus, PubMed/MEDLINE and Web of Science databases was performed to find published articles on patients with DTC and IR after treatment. The quality assessment of studies was carried out using QUADAS-2 evaluation. RESULTS: Eight articles were included in the systematic review. Six studies evaluated the prognosis and the prognostic factor in patients with IR, one study evaluated the role of 2-[18F]FDG PET-CT in the management of patients with IR and biochemical incomplete response and one study the risk factors for IR. CONCLUSION: Patients with DTC and IR to therapy have a probability of disease relapse < 15%. Tg value could be a predictor of disease progression. The role of 2-[18F]FDG PET-CT needs to be further investigated.

Histological changes in odontogenic parakeratinized keratocysts treated with marsupialization followed by enucleation.

BACKGROUND: The purpose of this study was to evaluate whether marsupialization treatment induces changes in the histology of odontogenic keratocyst epithelium and to compare our experience with the literature. MATERIAL AND METHODS: A retrospective revision of histological samples was performed. 5 patients with odontogenic keratocyst treated with marsupialization follow by enucleation were selected. Histologic evaluation analyzed the changes in the keratocyst epithelium after marsupialization in terms of type of keratinization, thickness of the epithelium and connective tissue, the presence of acanthosis, the presence and grade of fibrosis, the type and grade of inflammation and the presence and number of mitotic figures and daughter cysts. RESULTS: In our case series, a variation of para-keratinized into ortho-keratinized keratocyst was found in one case, and no significant increases were observed in the epithelium and capsule thickness, or even in the level of inflammation. However, we observed an increase in fibrosis and qualitative changes in inflammation type. CONCLUSIONS: Minor and major histological changes were associated with reduction in cyst volume, which resulted in a simpler and less invasive cystic enucleation after marsupialization.

Validation of the Killip-Kimball Classification and Late Mortality after Acute Myocardial Infarction / Validação da Classificação de Killip e Kimball e Mortalidade Tardia Após Infarto Agudo do Miocárdio

Background: The classification or index of heart failure severity in patients with acute myocardial infarction (AMI) was proposed by Killip and Kimball aiming at assessing the risk of in-hospital death and the potential benefit of specific management of care provided in Coronary Care Units (CCU) during the decade of 60. Objective: To validate the risk stratification of Killip classification in the long-term mortality and compare the prognostic value in patients with non-ST-segment elevation MI (NSTEMI) relative to patients with ST-segment elevation MI (STEMI), in the era of reperfusion and modern antithrombotic therapies. Methods: We evaluated 1906 patients with documented AMI and admitted to the CCU, from 1995 to 2011, with a mean follow-up of 05 years to assess total mortality. Kaplan-Meier (KM) curves were developed for comparison between survival distributions according to Killip class and NSTEMI versus STEMI. Cox proportional regression models were developed to determine the independent association between Killip class and mortality, with sensitivity analyses based on type of AMI. Results: The proportions of deaths and the KM survival distributions were significantly different across Killip class >1 (p <0.001) and with a similar pattern between patients with NSTEMI and STEMI. Cox models identified the Killip classification as a significant, sustained, consistent predictor and independent of relevant covariables (Wald χ2 16.5 [p = 0.001], NSTEMI) and (Wald χ2 11.9 [p = 0.008], STEMI). Conclusion: The Killip and Kimball classification performs relevant prognostic role in mortality at mean follow-up of 05 years post-AMI, with a similar pattern between NSTEMI and STEMI patients. .

Fundamento: A classificação ou índice de gravidade de insuficiência cardíaca em pacientes com infarto agudo do miocárdio (IAM) foi proposta por Killip e Kimball com o objetivo de avaliar o risco de mortalidade hospitalar e o potencial benefício do tratamento especializado em unidades coronárias (UCO) na década de 1960. Objetivos: Validar a classificação de Killip para mortalidade total em longo prazo e comparar o valor prognóstico em pacientes com IAM sem elevação do segmento ST (IAMSEST) em relação àqueles com elevação do segmento ST (IAMCEST), na era pós-reperfusão e de terapia antitrombótica moderna. Métodos: Foram avaliados 1906 pacientes com IAM confirmado, admitidos em UCO entre 1995 e 2011, com seguimento médio de cinco anos, para avaliação da mortalidade total. Curvas de Kaplan-Meier foram construídas para comparação da sobrevida por classe Killip e IAMSEST versus IAMCEST. Modelos de regressão de risco proporcional de Cox foram construídos para determinar a associação independente entre a classe Killip e a mortalidade, com análises de sensibilidade por tipo de IAM. Resultados: As proporções de óbitos e as distribuições das curvas de sobrevida foram diferentes conforme a classe Killip >1 (p <0,001) e similares entre IAMSEST e IAMCEST. Os modelos de risco identificaram a classificação de Killip como preditor significante, sustentado, consistente e independente de covariáveis relevantes (Wald χ2 16,5 [p = 0,001], IAMSEST) e (Wald χ2 11,9 [p = 0,008], IAMCEST). Conclusão: A classificação de Killip e Kimball desempenha papel prognóstico relevante na mortalidade em seguimento médio de cinco anos pós-IAM e, de modo similar, entre pacientes com IAMSEST e IAMCEST. .

Validation of the Killip-Kimball classification and late mortality after acute myocardial infarction.

BACKGROUND: The classification or index of heart failure severity in patients with acute myocardial infarction (AMI) was proposed by Killip and Kimball aiming at assessing the risk of in-hospital death and the potential benefit of specific management of care provided in Coronary Care Units (CCU) during the decade of 60. OBJECTIVE: To validate the risk stratification of Killip classification in the long-term mortality and compare the prognostic value in patients with non-ST-segment elevation MI (NSTEMI) relative to patients with ST-segment elevation MI (STEMI), in the era of reperfusion and modern antithrombotic therapies. METHODS: We evaluated 1906 patients with documented AMI and admitted to the CCU, from 1995 to 2011, with a mean follow-up of 05 years to assess total mortality. Kaplan-Meier (KM) curves were developed for comparison between survival distributions according to Killip class and NSTEMI versus STEMI. Cox proportional regression models were developed to determine the independent association between Killip class and mortality, with sensitivity analyses based on type of AMI. RESULTS: The proportions of deaths and the KM survival distributions were significantly different across Killip class >1 (p <0.001) and with a similar pattern between patients with NSTEMI and STEMI. Cox models identified the Killip classification as a significant, sustained, consistent predictor and independent of relevant covariables (Wald χ2 16.5 [p = 0.001], NSTEMI) and (Wald χ2 11.9 [p = 0.008], STEMI). CONCLUSION: The Killip and Kimball classification performs relevant prognostic role in mortality at mean follow-up of 05 years post-AMI, with a similar pattern between NSTEMI and STEMI patients.

How to improve retromandibular transmasseteric anteroparotid approach for mandibular condylar fractures: our clinical experience.

Fractures of the mandibular condyle are common and account for 25-35% of all mandibular fractures reported in the literature. Even with the development of a consensus on the preference for open reduction and internal fixation of these fractures, the clinician is still faced with a dilemma concerning the optimal approach to the ramus-condyle unit. Limited access and injury to the facial nerve are the most common problems. The most commonly used extraoral approaches are the submandibular, retromandibular and preauricular methods. In this study, we propose a modified cosmetic preauricular incision with a short end in the neck, to improve the transmasseteric anteroparotid (TMAP) approach previously described by Wilson et al. in 2005. We retrospectively analysed 13 patients treated in our department for mandibular condylar fractures. Post-operative complications, occlusal status, interincisal opening and joint tenderness were evaluated at 3 months after surgery. The wider skin incision described here provides a convenient approach for open reduction and rigid internal fixation, and good results were obtained. The follow-up ranged from 6 to 40 months.

Reconstruction of nasal skin cancer defects with local flaps.

Reconstruction of nasal defects must preserve the integrity of complex facial functions and expressions, as well as facial symmetry and a pleasing aesthetic outcome. The reconstructive modality of choice will depend largely on the location, size, and depth of the surgical defect. Individualized therapy is the best course, and numerous flaps have been designed to provide coverage of a variety of nasal-specific defects. We describe our experience in the aesthetic reconstruction of nasal skin defects following oncological surgery. The use of different local flaps for nasal skin cancer defects is reported in 286 patients. Complications in this series were one partial flap dehiscence that healed by secondary intention, two forehead flaps, and one bilobed flap with minimal rim necrosis that resulted in an irregular scar requiring revision. Aesthetic results were deemed satisfactory by all patients and the operating surgeons. The color and texture matches were aesthetically good, and the nasal contour was distinct in all patients. All scars were inconspicuous and symmetrical. No patient had tenting or a flat nose.

Tarsal strip technique for correction of malposition of the lower eyelid after treatment of orbital trauma.

PURPOSE: The transconjunctival, subciliary, subtarsal, and subpalpebral approaches for accessing the infraorbital rim and orbital floor have both advantages and disadvantages. The most common complications include rounding of the lateral canthal angle, lower eyelid retraction with inferior scleral show, and frank ectropion. MATERIALS AND PATIENTS: From 2000 to 2007, we treated 29 patients with lower eyelid malposition after surgery to manage the floor and infraorbital trauma (22 subciliary approaches, five transconjunctival approaches and lateral canthotomies, and two transconjunctival approaches). To correct lower eyelid malposition, we applied the tarsal strip technique in all patients. RESULTS: Twenty-five patients had scleral show and four patients had ectropion: three were previous treated using transconjunctival access and one using subciliary access. Twenty-six patients obtained satisfactory correction of eyelid malposition in a single-step surgical procedure, while three patients required a second surgical step to correct the remaining scleral show. Good aesthetic and functional results were achieved in all cases. CONCLUSIONS: All approaches to the infraorbital rim or orbital floor have the potential for postoperative sequelae. The tarsal strip technique is a relatively simple technique that oral and maxillofacial surgeons can use to manage lower lid malposition, such as scleral show and ectropion.

Structural studies of the Fur protein from Rhizobium leguminosarum.

The X-ray crystal structure of the apo-form of the Fur protein from Rhizobium leguminosarum has been solved at 2.7 A resolution. Small-angle X-ray scattering was used to give information on the solution conformation of the protein. The Fur homodimer folds into two domains. The N-terminal domain is formed from the packing of two helix-turn-helix motifs while the C-terminal domain appears primarily to stabilize the dimeric state of the protein.

[Meta-analysis of the Italian studies on short-term effects of air pollution]. / Metanalisi italiana degli studi sugli effetti a breve termine dell'inquinamento atmosferico.

BACKGROUND: In recent years, much attention has been given to review reports on the early effects of air pollution on health, measured through daily series of deaths and/or hospital admissions. A number of large planned meta-analyses (in which methods for data retrieval and processing are commonly planned a priori for all participating centers) are on going both in the US and in Europe. The National Mortality, Morbidity and Air Pollution Study included data from 90 US cities, whereas APHEA (Air Pollution and Health, a European Approach) considers data from about 30 european cities. The present paper summarizes methods and findings of MISA, a meta-analysis of data from 8 Italian cities. It belongs to an ad hoc supplement of Epidemiologia & Prevenzione (Epidemiol Prev 2001; 25 (2) Suppl: 1-72), the official Journal of the Italian Association of Epidemiology, which contains a full description of the study. MISA was launched on March 2000, within the project "Statistics, Environment and Health" (GRASPA), funded by the Italian Ministry of Education. Additional support was given by the Authorities of the 8 participating cities (from North to South: Turin, Milan, Verona, Ravenna, Bologna, Florence, Rome and Palermo). DAILY HEALTH DATA: Deaths certificate and hospital admission data have been collected respectively from the Local Health Authority and regional files. The same programme for retrieval of data on selected hospital admissions for acute conditions was used in the 8 cities. Main data are summarized in Table 1. DAILY CONCENTRATION OF POLLUTANTS: Most data were obtained from Regional Environmental Protection Agencies, which are responsible for environmental monitoring since 1993. Verona, Palermo and Milan (1990-94) data were obtained from local sources. Monitors with more than 25% of missing data were excluded. Meteorological data were collected by the same monitors and completed with data from monitors situated in the suburbs or (in Milan and Bologna) in the airport. The monitors were selected by a group of experts to ensure comparability. For SO2 and NO2 daily averages of hourly measurements were used, whereas concentrations of ozone and CO were estimated as the maximum 8 hours moving average. Total suspended particulate or PM10 were measured as 24 hours deposition. All analyses used the whole range of observed values (Table 2). Daily data were considered as missing when more than 25% of hourly data were not available. Missing data in one monitor were imputed as average of data from the remaining monitors weighted by the ratio between the specific monitor's year average and the general year average of all the selected city monitors. Missing data in one day were imputed as average of four days (preceding and following day, the same day of the previous and following weeks). In the city of Florence and Palermo PM10 concentrations were available. For the other cities we applied a conversion factor from PTS to PM10 (0.6 for Turin and 0.8 for all the others) estimated through validation studies. Ozone concentrations were used only where background monitors were available (Turin, Verona, Bologna and Florence) and limited to the warm season (May through September). METHODS: A common protocol for the city-specific analyses was defined on the basis of a structured exploratory analysis. The adopted basic model was a Generalized Additive Model for Poisson data. Effect estimates were age-adjusted (0-64, 65-74, 75+) and formal tests of interaction pollutant-age were conducted. In the first two age groups, indicator variables for seasonality were specified, and cubic splines with fixed number of degree of freedom were specified for the last age group and for all age groups for the morbidity data. Model adequacy was checked by residual analysis and inspection of the partial autocorrelation function. In a sensitivity analysis non linear pollutant effects were considered and overdispersed [table: see text] transitional models were fitted; the analysis was conducted for all lags 0-3 and some distributed lags (0-1, 1-2, 0-3); no multipollutant models were fitted. The same model was fitted to the city data. No model selection was done: Table 3 describes the steps in model building. In the meta-analysis, for each outcome, the estimates for each pollutant and for each city were combined using fixed and random effects models. Heterogeneity of effects was tested according to DerSimonian and Laird. Results were checked using a hierarchical bayesian model, which was used to investigate heterogeneity across cities in a meta-regression phase. Non informative priors were used. Posterior distributions of parameters of interest have been obtained with WinBUGS. 10,000 iterations (excluding [table: see text] the first 2000) were retained, while for the meta-regression 100,000 iterations (excluding the first 4000) were stored. To approximate the marginal posteriors only one sample out of five were used. Achieved convergence was assessed using the Gelman and Rubin approach. In the meta-regression the models specified were the following: [formula: see text] i denotes city, j calendar period (1990-1994; 1995-1999). The first model includes only period as effect modifier, while the second model other potential variables. The ui terms (which do not vary with j) represent city specific random effects. RESULTS: For each pollutant, the meta-analysis detected a statistically significant association with mortality for natural causes. But for ozone, positive associations were commonly found for death and hospital admissions for both cardiovascular and respiratory diseases. Indeed, the only estimates whose lower 95% confidence limit bore a negative sign regarded the association between PM10 and mortality from respiratory diseases. Ozone in the warm season was positively and significantly associated with daily mortality and mortality for cardiovascular diseases whereas other estimates did not reach statistical significance and some were negative (only lag 0-1 for external comparability are reported in Table 4). Risks were highest (up to 4%) for respiratory conditions (Table 4). They were more pronounced at lag 1-2 for mortality, and at lag 0-3 for hospital admissions. Age was an effect modifier for mortality, the elderly being more susceptible. In the random effect meta-analysis, at lag 1-2, excess risks for unit increase of the pollutants at age 75+ and at age 0-64 were respectively: 4.9% and -0.4% for SO2, 1.7% and 0.6% for NO2; 2.3% and 0.2% for CO. Corresponding figures for PM10 at lag 0-1 were 1.1% and 0.2%. The effect of PM10 on mortality [table: see text] was greater during the warm season (2.8% vs 0.8%). A complete analysis is reported in the Italian text. Here we provide some details on the effects of PM10, about which the residual heterogeneity across cities was highest (Table 4). In addition, the epidemiological evidence on the hazards from this fraction of particulate matter is more controversial. Table 5 reports the excess risk estimated through the meta-analysis in 1995-99 for a 10 micrograms/m3 increase of PM10 for some outcomes. Proper prior distributions (overdispersed normal and inverse gamma) were adopted in the final bayesian analyses. The sensitivity of results to the choice of the priors were investigated (we defined proper and improper uniform, student's t), obtaining comparable results. Total natural mortality was significantly heterogeneous across cities (Q = 18.96, 5 df, p < 0.001). City-specific estimates are represented graphically in Fig. 1. As expected, the confidence (credibility) intervals are widest [table: see text] for bayesian estimates, intermediate for those obtained under a random effects model, and narrowest for those found under a fixed effects model. Nevertheless, differences in point estimates are negligible. A North-South gradient in risk is obvious. Table 6 shows, for the cities for which mortality data were available, the improvement in precision and the shrinkage of effect estimates toward the overall mean introduced by the bayesian modelling. In the meta-regression, total mortality and a deprivation score were associated with greater effects. The excess risks on hospital admission were modified by the deprivation score and by the NO2/PM10 ratio. Overall, the risk estimates were greater in the calendar period 1995-99 and there was a North-South gradient, with larger effects in cities located in Central and Southern Italy (Florence, Rome, Palermo). CONCLUSIONS: The meta-analysis of the Italian studies on short-term effects of air pollution in 8 cities, MISA, exhibits the following features: With the exception of Naples, all greatest Italian cities were included; overall a population of 7 million was enrolled. The study protocol was accurate with regard to the selection of hospital admissions for acute conditions. Monitored data of concentration of pollutant were carefully evaluated before their inclusion in the meta-analysis. City specific analyses were carried out according to a common protocol controlling for seasonality, influenza epidemics, age and meterological variables; [table: see text] the protocol derived from a structured exploratory analysis. The meta-analysis was done using fixed and random effects models; a hierarchical bayesian model was fitted in a sensitivity analysis. The heterogeneity of effects across cities was investigated using a hierarchical bayesian model for meta-regression. While mortality data are of good quality, hospital admission data are more problematic. Since the filing criteria for the latter changed around 1995, comparability of results before and after such date is limited. Moreover, hospital admissions rely on availability of beds, the offer of which may be restricted during the warm season. Comparability of pollutant concentration estimates among cities may have been influenced by differences in monitor characteristics. (ABSTRACTTRUNCATED)

[Metallic elements in tissues surrounding internal rigid fixation (IRF) devices]. / Elementi metallici nei tessuti circondanti dispositivi per fissazione interna rigida (FIR).

BACKGROUND: Plates and other devices made by several alloys have been introduced to reach the stability of bone fractured fragments. Elements constituting alloys could be detected especially in organs, yet also in local tissues. Aim of the present study is the analysis of tissues surrounding IRF devices analyzing the morphology of released particles and studying the behavior of adjacent tissues to check metallic elements diffusion. METHODS: Biopsies were retrieved from 18 patients, aged 20 to 76 years. The patients received IRF by plates, screws and grids from 4 months to 9 years. They were divided into five groups according to the local phlogistic degree. Ordinary light microscopy, scanning electron microscopy and X-ray microprobe analysis (EDS system) was used to perform morphological investigations and identification of metal particles and elements. RESULTS: Metal particles or elements arising from plates, screws or grid may undergo tissular diffusion and cellular uptake. Not only Chromium, Iron or Aluminium but also Titanium may be easily released from devices and engulfed in tissues. In particular Titanium diffusion is evident in fibrous tissue surrounding IRF devices. Aluminium appears to be particularly accumulated in a persistent way in fibrous tissues and shows a characteristic embedding pattern in lamellar bone. CONCLUSIONS: The degree of local phlogosis appears to be strictly correlated to metallosis. Chromium, Iron, Aluminium and also Titanium, even if at different degree, give rise to phlogistic effects. Metallosis and phlogosis can produce a cascade process in which they are both the cause and the effect at the same time. The abundant release of Titanium, which does not normally produce clinical phlogosis as i.e. Aluminium, should be worthy of further investigations on its cellular effects.

Can a cyclo-oxygenase type-2 selective tocolytic agent avoid the fetal side effects of indomethacin?

We evaluated the efficacy and safety of nimesulide (100 mg orally twice daily for > 48 hours) in a pilot series of five women (two with twin pregnancies) at 24(+6) weeks (range 21(+3) - 27(+2)) in preterm labour which was unresponsive to intravenous ritodrine. Nimesulide therapy was continued for eight days (5-16) and was associated with a prolongation of pregnancy of 27 days (6-69). Oligohydramnios occurred in all seven fetuses after three to nine days of therapy, and in the five pregnancies that continued after discontinuation of nimesulide, it resolved within four days (2-7). None of the babies manifested permanent renal damage.

[Risk factors and neonatal outcomes in shoulder dystocia]. / Fattori di rischio ed esiti neonatali della distocia di spalle.

BACKGROUND: Shoulder dystocia (SD) is a rare obstetrical complication but linked with a high perinatal morbidity and mortality rate. SD has been associated to a series of maternal and fetal risk factors due to a multifactorial etiology. This study analyzes the incidence of SD, its morbidity and associated risk factors. METHODS: Cases of SD occurred at the St. Gerardo Hospital (Monza) between January 1992 trough December 1997 have been retrospectively reviewed. Obstetrical and feto-neonatal data regarding cases of SD were compared to data regarding all the cephalic vaginal deliveries occurred in the same period in our Center. RESULTS: A total of 14,157 cephalic vaginal deliveries were included in this study, of these 21 infants (0.15%) had SD. A significantly higher incidence of SD cases was found in fetal macrosomia, maternal diabetes, induction of labor by PGE2, use of obstetrical vacuum, length of first stage of labor > 4 hours in multiparas and > 8 hours in nulliparas, and length of second stage > 60 minutes, regardless of parity. A closed association was also observed between SD and birth trauma as brachial plexus injury and humerus fracture. CONCLUSION: The incidence of SD in our population (0.15%) is below the average reported in the literature (0.37-1.1%). The well-known risk factors, whose low positive predictive value can nevertheless modify obstetrical management, are confirmed.

[Treatment of maternal hyperthyroidism and fetal goiter]. / Trattamento dell'ipertiroidismo materno e gozzo fetale.

A fetal goitre is a potentially dangerous phenomenon because of mechanical obstruction and possible fetal thyroid function disorders. During pregnancy women with a history of Graves' disease under treatment with propylthiouracil (PTU) have an increased risk for fetal goitre. In this report a patient with Graves' disease diagnosed in early pregnancy and treated with PTU which resulted in a fetal goitre is described. The fetal thyroid status, investigated by percutaneous fetal umbilical cord blood sampling, was normal and the reduction of PTU dosage was sufficient to decrease goitre volume.

Laparoscopic cholecystectomy and the Peter Pan syndrome.

We report the case of a patient who experienced hemobilia a few weeks after undergoing laparoscopic cholecystectomy (LC). This condition was due to the rupture of a pseudo-aneurysm of the right hepatic artery in the common bile duct, probably caused by a clip erroneously fired during LC on the lateral right wall of the vessel. It also caused the formation of multiple liver abscesses and the onset of sepsis. This life-threatening complication led to melena, fever, epigastric pain, pancreatitis, liver dysfunction, and severe anemia, requiring urgent hospitalization and operation. In the operating theater, the fistula was closed, the liver abscesses drained, and a Kehr tube inserted. Thereafter, the patient's general condition improved, and she is now well. LC is often considered to be the gold standard for the management of symptomatic cholelithiasis. However, recent data have undermined that opinion. The apparent advantages offered by LC in the short term (less pain, speedier recovery, shorter hospital stay, and lower costs) have been overwhelmed by the complications that occur during long-term follow-up. When the late downward trend in the bile duct and the vascular injury rate are taken into consideration, the learning curve is prolonged. Therefore, LC should be regarded as the surgical equivalent of a modern Peter Pan-i.e., it is like a young adult who should make definitive steps toward becoming an adult but does not succeed in doing so. We report the case of a patient who experienced hemobilia a few weeks after undergoing laparoscopic cholecystectomy. Based on the facts in this case, we argue that the endoscopic procedure still needs to be perfected and cannot yet be considered the gold standard for selected cases of gallstone disease.

Hepatitis C virus infection is associated with a higher incidence of cholestasis of pregnancy.

To investigate a possible relationship between hepatitis C virus infection and cholestasis of pregnancy, we identified all cases of cholestasis of pregnancy (145/16,271) and hepatitis C virus infection (63/16,271) between January 1992 and December 1997. Serologic screening was performed universally. The rate of cholestasis of pregnancy was greater in women whose hepatitis C virus antibodies were positive rather than negative [15.9% (10/63) vs 0.8% (135/16,208), P < 0.001]. Among women with cholestasis of pregnancy, mean (standard deviation) gestational age at onset of symptoms and at delivery was significantly lower among women whose hepatitis C virus antibodies were positive compared with negative women: 28.9 (3.2) vs 34.3 (3.5) weeks, P < 0.001 and 36.3 (0.9) vs 37.0 (1.6) weeks, P = 0.03, respectively. These findings suggest that early occurrence of cholestasis of pregnancy may be an indication for serologic testing for hepatitis C virus.

Amnioreduction in emergency cerclage with prolapsed membranes: comparison of two methods for reducing the membranes.

To evaluate the effectiveness of amnioreduction in pregnancies requiring emergency cerclage placement, we performed a retrospective case-control study of all consecutive pregnant women with cervical dilation and effacement with prolapse of the fetal membranes in vagina between 16 and 26 weeks' gestation, who required placement of a McDonald emergency cerclage during the period January 1991-December 1997. Duration of pregnancy prolongation, rate of delivery before 32 weeks, and duration of neonatal hospital stay were compared between women in whom amniochorionic membranes were reduced at the time of cerclage placement using only intracervical Foley balloon catheter (controls; n = 7) and those who in addition underwent amnioreduction to facilitate cerclage placement (n = 9). Statistical analysis utilized Fisher's exact test and Wilcoxon rank sum test. A p value <0.05 was considered significant. There were no procedure-related ruptures of membranes. Gestational age at cerclage and rate of positive cervico-vaginal cultures were not different between the two groups. Gestation was prolonged for a median of 100 days (range 4 to 144 days) in the amnioreduction group and 10 days (2 to 133) among controls (p = 0.3). The rate of delivery before 32 weeks was significantly lower (1/7 vs. 6/8, p = 0.03) and the duration of neonatal hospital admission significantly shorter (median 3 vs. 37 days, p = 0.001) in the amnioreduction group than among controls. The amount of amniotic fluid withdrawn ranged from 220 to 340 mL. These findings suggest that amnioreduction at the time of emergency cerclage placement is associated with a lower rate of extreme prematurity and related neonatal morbidity.