Cervico-vaginal fetal fibronectin: predictive value during false labor

OBJECTIVE

The purpose was to determine to what extent fetal fibronectin was a discriminative test of preterm delivery in patients hospitalized for uterine contractions without modification of the cervix.

STUDY DESIGN

The prospective double-blind study included patients hospitalized between 24 and 34 week for false labor. Cervicovaginal swabs were obtained and assayed for the presence of fetal fibronectin by means of a monoclonal antibody assay.

RESULTS

Out of the 61 patients included, 18 showed a positive swab. The correlation of a positive result with preterm delivery revealed a sensitivity of 56%, a specificity of 81%, and positive and negative predictive values of 56% and 81% respectively. Meta-analysis of studies published shows that the presence of fibronectin represents a significant relative risk of 3.3 (IC: 2.5-42) of preterm delivery.

CONCLUSION

The presence of fetal fibronectin in cervicovaginal secretions of patients presenting with false labor indicates a major risk of preterm delivery.

Evaluation of liver transplantation for high-risk indications

BACKGROUND

Appropriate use of orthotopic liver transplantation (OLT) requires continued assessment of the indications for transplantation as a number of diseases are associated with a poor prognosis. High-risk patients are those who have a poor survival or high incidence of recurrent disease (patients with tumours, hepatitis B- or hepatitis C-induced cirrhosis, fulminant hepatic failure or primary graft non-function). In addition, retransplantation may be associated with a poor outcome.

METHODS

A retrospective review was made of the records of all adult patients undergoing OLT at this hospital between October 1985 and July 1994.

RESULTS

A total of 396 liver transplants were performed in 364 patients. The 1- and 3-year actuarial survival rates were 81 and 69 per cent respectively. The overall survival rate of high-risk patients was significantly lower than that for all OLT recipients (P < 0.05). While no patients transplanted for hepatitis C have developed graft failure, recurrent hepatitis occurred in 15 of 35 patients.

CONCLUSION

Strict selection criteria and appropriate perioperative investigations and interventions are required to improve the results of OLT in these high-risk patients.

[Routine prenatal care in Europe: comparison of the experience of nine gynecologic-obstetric services in eight different countries]

OBJECTIVE

The purpose of this study was to compare the routine pre-natal surveillance carried out in nine European Gyneco-Obstetric units.

MATERIAL AND METHOD

A survey was carried out between October 1992 and November 1993 with the aid of a questionnaire. The questionnaire contained 118 questions covering clinical examinations and explorations undertaken systematically during the first, second and third trimesters and at the end of pregnancy before delivery. To ensure that the replies were accurate, the survey was carried out on the spot in the units concerned with the head of the unit.

RESULTS

The survey revealed a certain number of differences in the surveillance carried out in the various units. The units did not all carry out systematic blood tests for toxoplasmosis, AIDS and hepatitis B at the first examination. The same applied to fasting blood glucose and the bacterial culture of the urine. Nor did all the units automatically undertake vaginal examination during the second and third trimesters and the English departments were not all convinced of the need for systematic ultrasound tests. Only five of the nine units undertook routinely cardiotocographic recordings of the fetal heart rate at the end of the pregnancy.

CONCLUSION

The differences observed in the various surveillance procedures simply reflect our uncertainty regarding the different tests we use to monitor pregnancies. At a time when financial constraints are forcing us to make choices, there is an urgent need to assess the effectiveness and the cost of the various elements of our prenatal monitoring.

Regional versus systemic chemotherapy in the treatment of colorectal carcinoma metastatic to the liver. Is there a survival difference? Meta-analysis of the published literature

BACKGROUND

A number of articles have appeared in the medical literature regarding regional infusion chemotherapy for the treatment of metastatic colorectal carcinoma confined to the liver. The results and conclusions have been varied. A meta-analysis of the literature was undertaken to determine if regional infusion chemotherapy using either 5-fluorouracil or floxuridine (FUDR) confers a survival advantage over systemic chemotherapy for the treatment of this disease.

METHODS

A MEDLINE search was conducted encompassing the period from January 1976 to May 1995. The search was narrowed to include only articles that referenced prospective randomized clinical trials. A total of 149 articles or abstracts were reviewed for potential eligibility in this meta-analysis. Six articles met the current study inclusion criteria. One and 2-year survival rates for each treatment modality were directly retrieved from each study or calculated from the Kaplan-Meier survival curves that were presented. Prior to pooling the estimates of the treatment survival differences, a test was conducted for homogeneity of the treatment effect using the test statistic proposed by DerSimonian and Laird 1986. The fixed effect model was then used to obtain summary estimates of the survival differences from the group of studies.

RESULTS

Regional infusion chemotherapy with FUDR produced a 10% (P = 0.041) and 6% (P = 0.124) increased survival at 1 and 2 years, respectively.

CONCLUSIONS

Based on this meta-analysis, it appears that hepatic artery infusion chemotherapy confers a modest survival benefit over systemic chemotherapy. Whether this is clinically relevant depends on the quality rather than just the duration of survival.

Regional versus systemic chemotherapy in the treatment of colorectal carcinoma metastatic to the liver. Is there a survival difference? Meta-analysis of the published literature

BACKGROUND

A number of articles have appeared in the medical literature regarding regional infusion chemotherapy for the treatment of metastatic colorectal carcinoma confined to the liver. The results and conclusions have been varied. A meta-analysis of the literature was undertaken to determine if regional infusion chemotherapy using either 5-fluorouracil or floxuridine (FUDR) confers a survival advantage over systemic chemotherapy for the treatment of this disease.

METHODS

A MEDLINE search was conducted encompassing the period from January 1976 to May 1995. The search was narrowed to include only articles that referenced prospective randomized clinical trials. A total of 149 articles or abstracts were reviewed for potential eligibility in this meta-analysis. Six articles met the current study inclusion criteria. One and 2-year survival rates for each treatment modality were directly retrieved from each study or calculated from the Kaplan-Meier survival curves that were presented. Prior to pooling the estimates of the treatment survival differences, a test was conducted for homogeneity of the treatment effect using the test statistic proposed by DerSimonian and Laird 1986. The fixed effect model was then used to obtain summary estimates of the survival differences from the group of studies.

RESULTS

Regional infusion chemotherapy with FUDR produced a 10% (P = 0.041) and 6% (P = 0.124) increased survival at 1 and 2 years, respectively.

CONCLUSIONS

Based on this meta-analysis, it appears that hepatic artery infusion chemotherapy confers a modest survival benefit over systemic chemotherapy. Whether this is clinically relevant depends on the quality rather than just the duration of survival.

Successful cord blood stem cell transplantation for congenital erythropoietic porphyria (Gunther's disease)

Congenital erythropoietic porphyria (Gunther's disease, GD) is a rare autosomal recessive disease. It results from the deficiency of uroporphyrinogen III synthase, the fourth enzyme on the metabolic pathway of heme synthesis. GD leads to severe scarring of the face and hands as a result of photosensitivity and fragility of the skin due to uroporphyrin I and coproporphyrin I accumulation. It also causes erythrocyte fragility leading to haemolytic anaemia. The other clinical features include hirsutism, red discolouration of teeth, finger-nails and urine and stunted growth. The outcome is poor, and the disfiguring nature of GD may partly explain the legend of the werewolf. No curative treatment was known until 1991, when the first case of BMT in GD was reported. The clinical and biological outcome after transplantation was encouraging, with an important regression of the symptoms of the disease, but the child died of CMV-infection 11 months after BMT. We report the second case of GD treated successfully by stem cell transplantation using umbilical cord blood from an HLA-identical brother in a 4-year-old girl suffering from severe GD. Our patient is very well 10 months after transplantation. We confirm that stem cell transplantation is curative for GD.

Acute reactant cytokines and neutrophil adhesion after warm ischemia in cirrhotic and noncirrhotic human livers

Animal studies suggest that acute phase reactant cytokines and polymorphonuclear leukocytes (PMN) may play a critical role in ischemia-reperfusion injury. To evaluate whether similar mechanisms are operative in human liver, six cirrhotic and nine noncirrhotic patients undergoing right hepatectomy were randomized for utilization of hepatic vascular exclusion (HVE) as a model of ischemia-reperfusion injury. Portal and systemic levels of acute reactant cytokines (interleukin 6 [IL-6], interleukin 1 [IL-1], tumor necrosis factor alpha [TNF-alpha]) and neutrophil adhesion in serial liver biopsy specimens were studied. Correlations among mediators, leukocyte adhesion, and markers of liver injury were also evaluated. Hepatic vascular exclusion resulted in substantial and reproducible changes in portal and arterial IL-6 levels in both cirrhotic and noncirrhotic patients. Portal and systemic cytokine levels were comparable in most instances, whereas levels were usually higher in cirrhotic patients than in noncirrhotic patients. Negative correlations were found between IL-6 levels at the time of reperfusion and later TNF-alpha levels. IL-6 levels correlated negatively with numerous markers of hepatocellular injury and the number of postoperative complications. Hepatic vascular exclusion increased neutrophils adhesion after reperfusion in cirrhotic patients but not in noncirrhotic patients. In cirrhotic patients, the degree of leukocyte adhesion after reperfusion correlated with several postoperative markers of liver injury. This study in humans shows that acute reactant cytokines are released during liver ischemia and, interestingly, that IL-6 levels strongly correlate with clinical and laboratory measures of injury. Further studies to evaluate possible causal relationship with hepatic injury are warranted, with emphasis on the role of IL-6 and PMN adhesion.

Antenatal diagnosis of upper urinary tract dilation by ultrasonography

The criteria for the detection of fetal pyelectasis are still controversial. Prenatal and postnatal data from 2,170 consecutive pregnant women who underwent at least one antenatal ultrasound scan were prospectively studied. Fetal pyelectasis was defined on the basis of a mean renal pelvis dimension > 5 or 10 mm before or after 28 weeks of gestation, respectively. Pyelectasis was detected in 95 (4.4%) fetuses. Eighty-nine among them were explored after birth. In 13 (13.7%) cases, an obstructive urinary tract abnormality, a severe vesicoureteral reflux, or a megaureter were diagnosed postnatally. In 29 (30.5%) cases, pyelectasis was confirmed postnatally, while complementary investigations ruled out an obstruction of the urinary tract. The incidence of urinary tract malformations was thus 0.60%, while the positive predictive value was 13.7%. We recommend to use a value not < 10 mm of the renal pelvis mean dimension beyond 28 weeks of gestation as a threshold for detection of fetal upper urinary tract obstruction, in the absence of ureteric and/or bladder dilation. Any value between 5 and 10 mm measured during the 2nd trimester of gestation should be confirmed by a second ultrasound examination performed during the 3rd trimester, before being considered pathological.

Lipiodol accumulation in hepatic hemangioma. Detection with osmium postfixation

Lipiodol has been used to increase the detectability of small primary neoplasms in the liver. We report a patient who was found to have lipiodol deposits in the liver one month after intra-arterial injection. The region was resected, under ultrasound control, because of the impression that the lesion was malignant. The specimen contained two small hemangiomas as well as many small dysplastic nodules (adenomatous hyperplasia) in a noncirrhotic parenchyma. To locate the lipiodol deposit in this case, the tissue was radiographed, postfixed in osmium tetroxide, and embedded in paraffin. Black osmium-stained deposits were found within the cavities of the hemangiomas but not in the dysplastic nodules. Most of the deposits were extracellular multivesiculated bodies with a small focus of lipid droplets engulfed by multinucleated foreign-body type giant cells. This report reinforces that hepatic lipiodol retention is not specific for hepatocellular carcinoma. We present, for the first time, the histologic appearance of lipiodol accumulation in an hemangioma. The value of osmium tetroxide postfixation for the detection of lipiodol is also demonstrated.

The regeneration of soft tissue and bone around implants with and without membranes

The popularity of osseointegration for the replacement of anterior teeth has placed an increased demand on the preservation of normal gingival anatomy. This has led to the development of a variety of soft-tissue and bone-augmentation techniques that either prevent tissue collapse or restore previously damaged areas of the alveolus. With bone grafts, barrier membranes, and autogenous connective-tissue grafts used in combination with each other or separately, lost structures can be reconstructed into a normal configuration for optimum esthetic restorations.

Nutritional status and function in patients following Whipple procedure compared with controls

OBJECTIVE

Despite the potential for nutritional deficits in patients undergoing pancreaticoduodenectomy or Whipple procedure, long-term assessment of nutritional status has largely been ignored. This study assessed nutritional status of 24 Whipple patients compared with matched post-cholecystectomy controls.

METHODS

Clinical assessment was by subjective global assessment, body composition was assessed by bioelectric impedance analysis and functional assessment was by respiratory muscle strength and skeletal muscle function performed by electrical stimulation of the ulnar nerve of the wrist and hand-grip dynamometry.

RESULTS

Whipple patients studied 4.6+/-0.7 years since surgery and controls (4.8+/-0.7 years since surgery) were all judged clinically to be in a good nutritional state. Compared with controls, Whipple patients had significantly lower body weight (Whipple: 72.5+/-2.8 kg, control: 83.9+/-3.3 kg, p<0.05) however, the mean body weight of both Whipple and controls was above ideal weight (Whipple: 113.3+/-4.3%, control: 122.3+/-3.7% p = NS). No significant differences in functional performance were observed between groups. Energy intake of Whipple and controls was also comparable. In the Whipple group, neither the extent of gastric resection or the pathological diagnosis had an effect on the nutritional parameters studied.

CONCLUSIONS

Long-term follow-up of patients having undergone Whipple procedure failed to reveal the presence of any nutritional or functional deficits suggesting that a full nutritional recovery is possible after this surgery.

Fetal pulse oximetry during labor of 62 patients

The objectives of the study were to assess the ability of a fetal pulse oximeter to measure the fetal oxygen saturation (SPO2) continuously during labor and to assess the correlation between readings of fetal pulse oximetry and cord blood gases at birth. The Nellcor N-400 Fetal Oximeter was used in 62 women prospectively. The mean SPO2 was unchanged at the different stages of normal labor. 53.3 +/- 9.1 to 50.1 +/- 11.8% (n = 50). The SPO2 recorded during the pushing phase of stage II (n = 40) was correlated significantly with umbilical cord arterial pH (r = 0.55; p = 0.0002), venous pH (r = 0.63; p = 0.0001), venous PCO2 (r = 0.47; p = 0.002) and venous PO2 (r = 0.39; p = 0.01). SPO2 was also correlated with scalp pH (r = 0.52; p < 0.05; n = 21). No side effects were noted. Fetal pulse oximetry could be useful to assess fetal oxygenation during labor and at birth.

Treatment of Budd-Chiari syndrome with portosystemic shunt or liver transplantation

BACKGROUND

Budd-Chiari syndrome is an uncommon disorder caused by obstruction to hepatic venous outflow, causing varying degrees of hepatic injury depending on the extent, severity, and acuity of the obstruction.

PATIENTS AND METHODS

We reviewed the indications for operative intervention and the results of treating 32 patients with Budd-Chiari syndrome seen at Toronto Hospital between 1968 and 1995.

RESULTS

Twenty-one patients underwent portosystemic shunt (PSS) and 7 patients underwent liver transplantation (LT) as their initial operative management. Three patients who initially had PSS subsequently required LT. Patients with cirrhosis found on biopsy and preservation of hepatocellular function were treated with PSS and showed no difference in outcome when compared with patients without cirrhosis (P = 0.35). Patients who were treated by PSS with retrohepatic vena caval compression, as shown by high caval gradients had outcomes similar to those for patients with low gradients (P = 0.31). Using the Kaplan-Meier method, 5-year survival of PSS patients was 57%. Liver transplantation was used to manage patients with hepatic decompensation, as well as patients with vena caval occlusion or failed PSS. The 5-year Kaplan-Meier survival for LT was 67%.

CONCLUSIONS

Both PSS and LT are effective options in the management of Budd-Chiari syndrome. Portosystemic shunt is the preferred initial approach even with cirrhosis or retrohepatic caval compression as long as there is preservation of liver function and a patent vena cava. Liver transplantation should be used as primary therapy for patients with irreversible hepatic decompensation or vena caval occlusion, and it can be an effective salvage procedure following failed PSS.

Sirenomelia and situs inversus: case report and review of the literature

We report a case of sirenomelia of the symelia dipus type which is associated with complete situs inversus. Sirenomelia is difficult to diagnose prenatally because of a frequently associated oligohydramnios. Symelia dipus type adds to the difficulty of the diagnosis, since the bones of the thighs and legs are fully formed. In fact, a close examination of the cases of sirenomelia previously reported in the literature shows that a prenatal diagnosis was achieved only when the oligohydramnios was no more than moderate and/or the associated malformation was of apus or unipus type. We propose a systematic amnioinfusion when one suspects symelia unipus type. Finally, the pathogenesis of sirenomelia is discussed, as the presence of a complete situs inversus in the case reported here could illuminate the debate concerning the origin of the malformation.

Resection margins for colorectal metastases to the liver: do they make a difference?

Objective: The authors determined an appropriate surgical treatment for liver metastases from colorectal cancers. Clinicopathologic featuresof metastatic lesions of colorectal cancers were studied.

Summary Background Data: Major hepatic resection is the usual procedure for treatment of hepatic metastases from colorectal cancers.

Methods: Forty consecutive patients who underwent hepatic resections were prospectively studied, for a total of 89 metastatic liver tumors.

Results: Metastatic tumor often extended along Glisson’s capsule, including invasion to the portal vein (9 cases), the hepatic vein (3 cases), the bile duct (16 cases), and the nerve (6 cases). The main tumor had small satellite nodules in only one patient, and there were no microscopic deposits in the parenchyma, even within 10 mm from the metastatic tumors. Fibrous pseudocapsule formation was observed in 28 patients.

Discussion: The rarity of intrahepatic metastasis from metastatic tumor supports nonanatomic limited hepatic resection as the procedure of choice for metastatic colorectal cancer in the liver. The spread via Glisson's capsule should be taken into consideration for complete tumor clearance.

Surgical treatment of noniatrogenic trauma of the femoral arteries

Trauma to the femoral arteries corresponds to 30 percent of all arterial traumas. The authors reviewed 74 patients with noniatrogenic trauma of the femoral arteries treated from January 1991 to December 1993. Ages ranged from 11 to 50 years, with a mean of 24. Seventy-one patients were male and three female. Fifty-two patients (70.2 percent) were white, 20 (27 percent) were black and two (2.8 percent) were Asian. Trauma due to firearms had the highest incidence, with 61 cases (82.4 percent). Absence of pulse was the most frequent clinical symptom (62.5 percent). Severe ischemia, with risk of loss of limb, was found in 66.2 percent of the cases. The superficial femoral artery was impaired in 77 percent of the cases. A preoperative arteriography was performed on only five patients, victims of multiple penetrating trauma or an asymptomatic penetrating wound along a vessel passage. In six cases, arterial and venous ligature was the chosen procedure. In three cases, a primary arterial anantomosis was performed. Simple arterriorraphy was feasible in one patient. In 64 of the patients, a venous graft was undertaken using a segment of the inverted great saphenous vein withdrawn from the other lower limb. Fasciotomoy was used in 32 patients (43.2 percent), all of whom exhibited pasting of the lower limb muscles at admission. One patient died during the immediate postoperative period as the result of multiple organ failure caused by polytraumatism. Preservation of the limb was attained in 72 patients (97.3 percent) Severe, previously-incurred ischemia was responsible for the only two amputations, aggravated by an exceedingly long delay between the time of injury and surgery. One of these patients, in addition to severe ischemia, had extensive injuries to the soft tissues. We conclude that trauma of the femoral arteries, attended while the limb still maintains its vitality, has a positive clinical outcome with a high rate of limb preservation. Mortality usually results from injury to other organs.

Spontaneous regression of fetal pulmonary sequestration

The prenatal diagnosis of pulmonary sequestration can usually be made by the third trimester of pregnancy, from the combination of an intrathoracic mass and indirect signs such as cardiac deviation, fetal hydrops, pleural effusion and polyhydramnios. We describe four cases in which pulmonary hyperechogenicity was detected before 26 weeks' gestation. In three cases the hyperechogenic mass was isolated. In all cases it had mostly regressed during the pregnancy. A review of the cases of isolated pulmonary sequestration that have been diagnosed during the antenatal period is presented. Antenatal evolution was found to be unpredictable regardless of the type or severity of the case at the first diagnosis. We propose a classification to define more clearly the optimal management of pulmonary sequestration.

Bending overload and implant fracture: a retrospective clinical analysis

Thirty-nine patients with implant fractures treated by three of the authors have been analyzed as to probable causes. Thirty-five (90%) of the fractures occurred in the posterior region. Thirty (77%) of the prostheses were supported by one or two implants, which were exposed to a combination of cantilever load magnification and bruxism or heavy occlusal forces. It was concluded that prostheses supported by one or two implants and replacing missing posterior teeth are subjected to an increased risk of bending overload. The literature review indicates that the fracture frequency is low in these situations and this study demonstrates that with appropriate treatment planning, such overload situations can essentially be prevented.