Intrahepatic cholestasis of pregnancy - Time to redefine the reference range of total serum bile acids: A cross-sectional study

Objective

To establish pregnancy‐specific reference ranges for fasting and postprandial total serum bile acid (TSBA) concentrations.

Design

Cross‐sectional study.

Setting

Tertiary‐care university hospital.

Population

Healthy pregnant women at term admitted to the Obstetrics Department over a period of 1 year. Exclusion criteria were an established diagnosis of intrahepatic cholestasis of pregnancy (ICP) or any coexisting condition of increased risk for ICP.

Methods

Both fasting (after 8–14 h of fasting) and postprandial (2 h after meal) TSBA concentrations were measured in 612 women (with 528 fasting samples and 377 postprandial samples) by automated enzymatic spectrophotometric assay.

Main outcome measures

Fasting and postprandial TSBA concentrations in 612 women.

Results

Reference intervals of 4.4–14.1 μmol/L for fasting TSBA and 4.7–20.2 μmol/L for postprandial TSBA were established. The postprandial values were significantly higher than the fasting values, with a median increase of 1.0 μmol/L (p < 0.0001). A correlation between fasting TSBA concentrations and postprandial concentrations was found, as well as correlations with fetal sex, parity and assisted reproductive technologies. A seasonal pattern was noticed for both fasting and postprandial TSBA, with the highest values measured in the winter season (p < 0.01 and 0.02, respectively)

Conclusions

Normal pregnancy is associated with mild hypercholanaemia, and therefore a higher threshold should be considered for the diagnosis of ICP. We suggest using the upper reference limits observed in our healthy pregnant population (14 μmol/L for fasting TSBA and 20 μmol/L for postprandial TSBA). As the fasting measurement is more specific for the diagnosis, and the postprandial measurement is essential for the assessment of severity, it is recommended to measure both values rather than use random sampling.

Tweetable abstract

Normal pregnancy is associated with mild hypercholanaemia, a higher threshold should be considered for the diagnosis of ICP.

Normal pregnancy is associated with mild hypercholanaemia, a higher threshold should be considered for the diagnosis of ICP.

Linked article: This article is commented on by Ovadia et al., pp. 1897–1898. in this issue. To view this minicommentary visit https://doi.org/10.1111/1471‐0528.17171

Exploring the concept of eating dyscontrol in severely obese patients candidate to bariatric surgery

Eating dyscontrol constitutes a potential negative predictor for the outcome of treatment strategies for obese patients. The aim of this study was to examine the qualitative characteristics of eating dyscontrol in obese patients who engage in binge eating (BE) compared with those who do not (NBE), and to analyse the relationship between eating dyscontrol and axis-I, axis-II, spectrum psychopathology using instruments that explore mood, panic-agoraphobic, social-phobic, obsessive-compulsive and eating disorders spectrum psychopathology (SCI-MOODS-SR, SCI-PAS-SR, SCI-SHY-SR, SCI-OBS-SR, SCI-ABS-SR). This was a cross-sectional study involving a clinical sample of adult obese patients with severe obesity (average body mass index = 45 ± 8 kg m(-2) ) and candidate to bariatric surgery who were recruited between November 2001 and November 2010 at the Obesity Center of the Endocrinology Unit, University Hospital of Pisa. All participants completed a face-to-face interview, including a diagnostic assessment of axes-I and II mental disorders (using the Structured Clinical Interview for Manual of Mental Disorders, fourth edition [SCID]-I and SCID-II) and filled out self-report spectrum instruments. Among obese patients not affected by BE, eating dyscontrol was highly represented. Indeed, 39.7% (N = 177) of subjects endorsed six or more items of the Anorexia-Bulimia Spectrum Self-Report, lifetime version domain exploring this behaviour. The cumulative probability of having axis-I, axis-II and a spectrum condition disorder increased significantly with the number of eating dyscontrol items endorsed. In both BE and NBE obese subjects, eating dyscontrol may represent an independent dimension strongly related to the spectrum psychopathology and axes I/II disorders. A systematic screening for eating dyscontrol symptoms by means of self-report spectrum instruments may be valuable to assign specific treatment strategies.

[Toxic megacolon: report of 2 clinical cases and review of the literature]

The authors present two cases of toxic megacolon. A proctocolectomy with ileostomy was performed in both cases. One of the two cases was detected late; the patient underwent surgery in desperate conditions and died on postoperative day one. The authors regard a prompt diagnosis as fundamental for the correct timing of the surgical approach in patients with toxic megacolon and severe acute colitis. Clinical and laboratory findings and, above all, plain films of the abdomen should be evaluated very carefully. The authors suggest total proctocolectomy with section-suture of the rectal stump at levator level and ileostomy, which makes it possible to avoid postoperative rectal haemorrhages and recurrences.

[Skeletal changes induced by radiotherapy. A study of subjects with retinoblastoma. II]

The authors examine the dental and skeletal alterations consequent to the use of radiotherapy as the elective method of treating retinoblastoma, an endobulbar neuroectodermal tumour typical of early infancy. The authors revise the basic concepts of radiobiology and the modifications induced by radiation in developing tissues with reference to both alterations at a microscopic (histological) level and those at a macroscopic level, namely of a morphological and structural nature. In the first part of the study the authors examine the damage to dental structures relating to both developing tissues and damage to mature tissue. The second part of the paper analyses radiation damage on cartilage and bone tissues in the process of formation and the authors present their documentation in the form of iconographic and radiographic material together with an esthetic face analysis performed using Rickettz's method in three cases referred to their attention.

[Dental changes induced by radiotherapy: a study of subjects with retinoblastoma. I]

The authors examine the dental and skeletal alterations consequent to the use of radiotherapy as the elective method of treating retinoblastoma, an endobulbar neuroectodermal tumour typical of early infancy. The authors revise the basic concepts of radiobiology and the modifications induced by radiation in developing tissues with reference to both alterations at a microscopic (histological) level and those at a macroscopic level, namely of a morphological and structural nature. In the first part of the study the authors examine the damage to dental structures relating to both developing tissues and damage to mature tissue. The second part of the paper analyses radiation damage on cartilage and bone tissues in the process of formation and the authors present their documentation in the form of iconographic and radiographic material together with an esthetic face analysis performed using Ricketts' [correction of Rickettz's] method in three cases referred to their attention.

[Group educational intervention in diabetic foot: the objectives, pedagogical strategies, level of knowledge and results]

Detailed contents and aims of an educational intervention for diabetic foot are presented, together with evaluation tools and results at 3, 6 and 12 month interval after the course. Knowledge level and "health" of the foot were assessed at 12 month interval on 2/3 of the 100 diabetic patients originally exposed to the educational intervention. After 12 months 80% of patients showed a good retention of knowledge on practical issues related to foot care, while 77% of patients with persistent foot problems were not independent (because of hypo-mobility or sight problems) in foot care.

[The methodology and planning of an educational intervention in diabetic foot]

Diabetic foot is considered one of the most threatening and disabling complications for a diabetic patient: lesions of the extremities can become so severe that the person may risk the amputation of the toe, foot or leg. Methodology of planning and implementation of an educational intervention for the prevention of the diabetic foot is presented in its various steps: from the identification of priorities and contents to the problems and difficulties encountered in the implementation of the program.

[A proposed check on the educational role of the professional nurse with the diabetic patient]

The nursing personnel of a day hospital for diabetic patients selected at random two 30 patients groups out of the cohort of those who had followed an educational course in the same day hospital, and out of the cohort of first contacts with the hospital. A formal evaluation has been made on two topics: the correctness of the technical execution of various procedures, the patient's perception of the factors which could play a role in determining the quality of communication between nurses and patients. Patients who were exposed to the original course appear to perform better. Along the same line, patients of the day hospital seem to share a status of conscious acceptance of the disease and of its direct personal implications.

Evaluation of cerebral blood flow changes by transfontanelle Doppler ultrasound in infantile hydrocephalus

Doppler ultrasound investigation of cerebral blood flow velocity was performed in hydrocephalic infants through the anterior fontanelle. Systolic (S) and end-diastolic (D) frequency values recorded on the anterior cerebral artery were used to define the pulsatility index (PI) calculated from the equation PI=S-D/S. Comparison between systolic, end-diastolic and pulsatility index values of 50 normal infants and 10 hydrocephalic infants showed a statistically significant difference (P less than 0.05) for systolic and pulsatility index values. However, no significant difference was found for end-diastolic values. The authors believe that the phenomenon could be explained as an increase of the cerebrovascular compliance which counteracts the increase of the perivascular pressure in an attempt to maintain a normal cerebral blood flow. Therefore, the transfontanelle Doppler ultrasound technique may provide a useful and early tool in diagnosing cerebral blood-flow changes in hydrocephalic infants.

[Neonatal necrotizing enterocolitis (NEC). Observations of 21 cases studied from 1977 to 1980]

We have carried out a study together with neonatologists, paediatricians, paediatric surgeons and paediatric radiologist on the etiopathogenic, clinical-statistical, therapeutical and evolutionary aspects of NEC during the period from 1977 to 1980 in the Neonatology Clinic and in the Paediatric Surgery Department University of Bologna. The most important data were as follows: a high percentage of full-term newborns, the apparently unfavourable action of artificial feeding, a little amount of infectious etiology, an absence of predisposing factors in more than half the cases, an uniform symptomatology in a lot of patients with adverse evolution in the cases of secondary colic stenosis. The mortality was 33 percent, specially among the small for gestational age infants. The surgical therapy during four years period was modified technically, i.e. there was an orientation towards conservative surgery. The final surgical operation has recently been made right after the fourth month from the acute crisis as it has recently been demonstrated that secondary stenosis always occurs during this period of time. Long - term follow - ups showed: completely satisfactory progress in patients treated only with medical therapy, particularly unfavourable evolution in patients after a more demolishing - type of operation (resectioning of the last ansa of ileum and ileum - caecum valve), considerable improvement in auxological and nutritional parameters also in the latter cases after the final surgical operation.