Antibiotic administration in patients with preterm premature rupture of membranes reduces the rate of histological chorioamnionitis: a prospective, randomized, controlled study

OBJECTIVE

To determine whether antibiotic administration in patients with preterm premature rupture of membranes is associated with a reduction in the rate of histological chorioamnionitis and funisitis.

METHODS

One hundred consecutive patients with preterm premature rupture of membranes and no labor between 24 and 34 weeks were invited to participate in this study. Eligible patients randomly received either clindamycin-gentamicin for 7 days or placebo, and were managed expectantly until 35 weeks unless fetal or maternal indications developed. Microbial invasion of the amniotic cavity was defined as the presence of a positive amniotic fluid culture obtained by transabdominal amniocentesis. Cervicovaginal infection was diagnosed when bacterial vaginosis or a positive culture for cervicovaginal pathogens or facultative bacteria associated with a significant increase in the white blood cell count were found. Histological chorioamnionitis was based on the observation of polymorphonuclear leukocyte infiltration of the chorionic plate or the extraplacental fetal membranes. Funisitis was diagnosed in the presence of polymorphonuclear leukocyte infiltration into the umbilical vessel walls or Wharton jelly. Statistics were performed using contingency tables.

RESULTS

Seventy-one patients with available histological study of the placenta were included. Thirty-five women received antibiotics and 36 were given placebo. Patients who received antibiotics had a significantly lower rate of histological chorioamnionitis than patients who received placebo (46% (16/35) vs. 69% (25/36), respectively; p < 0.05). This effect was more pronounced among women with microbial invasion of the amniotic cavity and/or cervicovaginal infection (58% vs. 89%, respectively; p < 0.01). Antibiotic therapy was associated with an increase in the frequency of placentas without histological abnormalities (29% vs. 6%; p < 0.01). The frequency of funisitis was not different between groups.

CONCLUSION

Administration of antibiotics in patients with preterm premature rupture of membranes is associated with a significant reduction in the incidence of histological chorioamnionitis but it does not modify the frequency of funisitis.

Long-term follow-up of bone mass after orthotopic liver transplantation: effect of steroid withdrawal from the immunosuppressive regimen

Glucocorticoids have been suggested to play a major role in transplantation-related osteopenia. In this study we assess the long-term changes and the effect of steroid withdrawal from the standard immunosuppressive regimen on bone mineral density (BMD) after orthotopic liver transplantation (OLT). Sixty-nine non-osteoporotic patients (20 women, 49 men), aged 48 +/- 9.5 years (mean +/- SD), and with a follow-up of 58.3 +/- 23.2 months (range 24-121 months) were studied. Immunosuppressive treatment consisted of prednisone, cyclosporin A and azathioprine. In 41 patients (group A), prednisone was tapered and withdrawn after 36.2 +/- 19.3 months (range 13-79 months), whereas in 28 patients (group B) prednisone was maintained. BMD in the spine (L1-L4) was serially measured by dual-energy X-ray absorptiometry (Hologic QDR 1,000w) at baseline, before steroid withdrawal and at the end of study. Age- and sex-matched Z-scores of BMD were calculated. No differences were found in age, body mass index, time since OLT, or baseline BMD between the two groups. BMD had significantly increased in both groups at the end of follow-up period (group A, +8.1 +/- 8.7%; group B, +3.2 +/- 8.0%, p < 0.05). However, the Z-score was significantly higher in group A than in group B at the end of study (-0.44 +/- 1.05 vs -0.99 +/- 0.77; p<0.05). BMD recovery was lower in pre-OLT biliary cirrhosis patients. Bone mass improvement was independent of the time since OLT in both groups, and of the time of steroid withdrawal in group A. Our data confirm that steroid withdrawal accelerates the recovery of bone mass in patients who have undergone a successful liver transplantation.

Incidence and predisposing factors for incisional hernia in patients with liver transplantation

BACKGROUND

Cirrhotic patients who are transplanted have a high risk of developing incisional hernia (IH).

MATERIALS AND METHODS

We have analysed the incidence and treatment of IH in 465 patients with liver transplantation (LT). In order to find predisposing factors, we compared these patients with a similar group of patients with LT without IH. Fifty-four patients (11.6%) developed an IH. Forty-six of these (85%) were males, and in 37% the entire laparotomy incision was involved. Forty patients have been operated on for the hernia, three by primary repair and 37 (92.5%) with a polypropylene mesh. After a follow-up of 42 months, 6 (15%) IHs recurred. Comparing groups, IH patients were older (P<0.05), of male gender (P<0.001), and received more steroids (P<0.01). The IH rate was not related to suture material.

CONCLUSIONS

Our rate of IH is perhaps reasonable in these high risk patients. It appears that IH can be reduced if steroids are reduced or avoided. We recommend a large mesh for repair.

An anorexic lipid mediator regulated by feeding

Oleylethanolamide (OEA) is a natural analogue of the endogenous cannabinoid anandamide. Like anandamide, OEA is produced in cells in a stimulus-dependent manner and is rapidly eliminated by enzymatic hydrolysis, suggesting a function in cellular signalling. However, OEA does not activate cannabinoid receptors and its biological functions are still unknown. Here we show that, in rats, food deprivation markedly reduces OEA biosynthesis in the small intestine. Administration of OEA causes a potent and persistent decrease in food intake and gain in body mass. This anorexic effect is behaviourally selective and is associated with the discrete activation of brain regions (the paraventricular hypothalamic nucleus and the nucleus of the solitary tract) involved in the control of satiety. OEA does not affect food intake when injected into the brain ventricles, and its anorexic actions are prevented when peripheral sensory fibres are removed by treatment with capsaicin. These results indicate that OEA is a lipid mediator involved in the peripheral regulation of feeding.

Choledochocholedochostomy conversion to hepaticojejunostomy due to biliary obstruction in liver transplantation

Choledochocholedochostomy with tutor (CC-T) or without (CC) is the technique of choice for biliary reconstruction in orthotopic liver transplantation (OLT), however, its rate of complications is high and does not decrease significantly over the years. Biliary obstruction is the most frequent complication and surgical treatment frequently involves conversion to hepaticojejunostomy (H-J). Out of 412 patients (448 OLTs) analyzed retrospectively, 74 (18%) presented biliary complications and 25 (6%) required conversion to H-J because of biliary obstruction, generally due to anastomotic stenosis (17 patients, 68%). Sixteen out of the 25 presented after the first 3 months, and in two patients, stenosis was secondary to arterial thrombosis. Anastomotic stenosis was more frequent in the CC group than in the CC-T group (9.9% versus 2.6%, p < 0.05). Sixteen patients (64%) underwent percutaneous dilatations, but the response was only transitory. There were no postoperative deaths. At the follow-up, three (12%) of the 17 surviving patients presented episodes of cholangitis which required percutaneous dilatations (1), revision of the H-J (1), or conversion to hepaticojejunoduodenostomy (1). Mean survival of patients with H-J was 70.9%, and the actuarial survival rate was 68% at 5 years. This does not differ from the actuarial survival in our series of transplanted patients (65%). CC or CC-T (in selected cases) is an adequate biliary reconstruction for OLT, in spite of the fact that a small number of patients will require conversion to H-J. H-J is an excellent technique of rescue in cases of biliary obstruction that are not possible to resolve by percutaneous dilatations.

Long-term biliary complications after liver surgery leading to liver transplantation

Chronic biliary obstruction with repeated bouts of cholangitis adversely affects quality of life and may lead to secondary biliary cirrhosis with liver failure. We reviewed our experience with chronic biliary complications after surgical treatment of various diseases that at the end needed a liver transplantation. Twelve patients with previous biliary surgery developed secondary biliary cholangitis, secondary biliary cirrhosis, or both. Seven had surgery for liver hydatid disease by Echinococcus granulosus, another four had complicated biliary surgery unrelated to hydatid disease, and one had a history of a traffic accident with liver trauma and hepatectomy with chronic biliary fistula. The repeated cholangitis attacks and in two cases of hydatid disease the development of biliary-bronchial fistulas made these patients' lives miserable. All had had previous surgical procedures that made the transplantation procedure more difficult. Nevertheless, patient survival and graft actuarial survival after liver replacement were 75.0% and 69.2%, respectively, at 5 years.

Liver transplantation and hepatitis C virus. Results in a Spanish center since 1989

BACKGROUND/AIMS

Hepatitis C-related liver disease is the main indication for liver transplantation in many centers. Viral RNA remains after transplantation in almost 100% of the patients, and more recent reports show a graft hepatitis rate of about 90%. The progression of this hepatitis seems to be quicker than in the nontransplant setting.

METHODOLOGY

From June 1989 to October 2000, 197 adult patients had 213 for HCV-related liver disease at our institution. Basal immunosuppression consisted of a triple therapy with cyclosporine, azathioprine and steroids, or dual therapy with tacrolimus and steroids. None of the patients was treated with antivirals after liver transplantation.

RESULTS

Pure HCV-related cirrhosis was the indication for liver transplantation in 114 patients, another 14 with hepatocellular carcinoma, 8 associated metabolic diseases, 43 high alcohol intake, 4 hepatitis B, 5 cholestatic diseases, and 3 other diseases. Six patients out of the 197 transplanted in this period were already grafted before this time, and had their first retransplantation of the liver after 1989 (their first liver transplantation was done when HCV was not known). Sixteen additional retransplantation procedures were done in the period considered. Hepatitis was diagnosed in 84.3% of the grafts biopsied later than 90 days after liver transplantation (118/140), and in 92.9% if it was done after one year (92/99). Cirrhosis was diagnosed in 21 grafts at a mean time of 1004.7 days, 21.2% of the grafts biopsied after 1 year and 28.6% after 2 years. Nine grafts in 8 patients were diagnosed as fibrosing cholestatic hepatitis. Patient actuarial survival was 80.9%, 69.7%, 67.5% and 50.6% at 1, 3, 5 and 10 years. Liver failure and hepatoma recurrence were the cause of death in 42.4% of the patients. Actuarial graft survival was 75.2%, 64.9%, 63.5% and 48.6% at 1, 3, 5 and 10 years, and was significantly affected by Child stage (B vs. C, P = 0.004). When compared to 228 non-HCV- infected patients with chronic parenchymatous disease, these had an almost significantly better patient survival (P = 0.0577), but a nonsignificant difference in graft survival. Graft loss related to liver causes was 17.6% in HCV+ patients 14.6% in HCV- patients. Liver causes of death were 14.0% in HCV+ patients and 4.8% in HCV-patients (P = 0.002).

CONCLUSIONS

HCV infected liver transplantation recipients present very often graft hepatitis, which may progress to advanced stages in a quite short interval. Mid-term patient and graft survival is comparable to those of non-HCV recipients, but causes of death related directly to liver disease are more common in HCV+. This makes one think that long-term prognosis (more than 10 or 15 years) will be worse in HCV patients.

Synthesis of photo- and electroactive stilbenoid dendrimers carrying dibutylamino peripheral groups

[structure: see text]. A novel convergent synthetic route for the preparation of functionalized and fluorescent stilbenoid dendrons built on the 1,3,5-benzene core and endowed with a periphery of dibutylamino groups has been developed. Long alkyl chains have been incorporated on the peripheral amino moieties to increase the solubility of the final products. Good donor ability of the new dendrimers has been observed by cyclic voltammetry measurements as a result of the presence of the peripheral dibutylaniline moieties.

Cost-effectiveness of influenza vaccination in high-risk children in Argentina

OBJECTIVES

our study aimed to evaluate the cost-effectiveness of influenza vaccination in high-risk children in Argentina.

METHODS

a decision analysis model was performed, using data from published and unpublished sources, to compare two strategies--to vaccinate or not to vaccinate. We simulated the expected consequences of vaccination on direct medical costs, related to disease management and indirect costs, related to lost parental working days (absenteeism).

RESULTS

Using base-case assumptions vaccination of high-risk children aged 6 months to 15 years old, in Argentina (estimated cohort of 1184748) would prevent 207331 cases of influenza, resulting in a reduction of 58052 days of hospitalization and 207331 outpatient visits. Vaccination would lead to net savings of US$ 11894870 per vaccinated cohort (US$ 10.04 per vaccinated child).

CONCLUSION

our economic analysis shows that in Argentina, routine vaccination of high-risk children against influenza would be cost saving for society.

Presence of fed β-carotene in digesta, excreta, blood, and hepatic and adipose tissues of Holstein steers

Eight animals were fed a diet without added β-carotene for 49 d and then supplemented with four levels of β-carotene (0, 5.5, 44 or 352 mg kg–1dry matter) for 30 d; the two-phase procedure was then repeated. Steers were killed at the end of the second period. Concentrations of β-carotene were: 0, 0, 227.2 and 2011 mg dL–1 (P < 0.05) in ruminal fluid; 0, 0, 533.7 and 4418 mg dL–1 (P < 0.05) in duodenal fluid; 0, 4.03, 14.91 and 90.64 mg g–1 (P < 0.05) in dry faeces; 0.8, 1.2, 4.7 and 8.1 mg g–1 (P < 0.05) in liver; 0.07, 0.15, 0.5 and 3.7 mg g–1 (P < 0.05) in subcutaneous fat; 0, 0, 0.09 and 0.23 mg g–1 (P < 0.05) in kidney fat for dietary treatments with 0, 5.5, 44 and 352 mg β-carotene kg–1 DM, respectively. The dose of β-carotene was reflected in retinol concentrations in liver: 101.1, 113.6, 161.7 and 199.6 mg g–1 (P < 0.05), but not in subcutaneous or kidney fat (P > 0.1). The estimated β-carotene digestibilities were 66.25, 84.39 and 88.14% for treatments with 5.5, 44 and 352 mg β-carotene kg–1 DM, respectively (P < 0.01). The results suggest a high capacity of bovine tissues to store β-carotene and probably a limited capability to convert β-carotene into vitamin A. Key words: β-carotene digestion, blood concentration, deposition, steers

Safety and immunogenicity of a pediatric formulation of inactivated hepatitis A vaccine in Argentinean children

BACKGROUND

Children are a reservoir of hepatitis A virus and must be considered as primary targets of any immunization strategy. The safety and immunogenicity were evaluated for a new formulation of an inactivated hepatitis A vaccine, Avaxim 80 units, containing one-half the antigen dose of the adult formulation.

METHODS

The safety of two doses of this vaccine given 6 months apart was evaluated in an open study in 537 Argentinean children 12 months to 15 years old. Immunogenicity was evaluated at Weeks 0, 2, 24 and 27 in a subgroup of 120 subjects.

RESULTS

Two weeks after the first vaccine dose, >99% of initially seronegative children had seroconverted (titers > or =20 mIU/ml), with a geometric mean titer of 98.5 mIU/ml. Before booster at 24 weeks all subjects had seroconverted. A strong anamnestic response was observed after the second dose at which time the geometric mean titer had increased >35-fold, and antibody titers were consistent with long term protection. Immediate adverse reactions were observed in 3 of 537 (0.6%) subjects after the first dose. Local reactions were mild and transient and did not increase with subsequent doses. Among the systemic events reported during the 7-day follow-up period, 37 cases of fever after the first dose and 22 cases after the second dose were reported. Only 3 cases of fever were clearly related to vaccination (< or =38.2 degrees C) after the first injection, all of which subsided in less than 1 day.

CONCLUSIONS

This study demonstrated the safety and immunogenicity of a pediatric formulation of hepatitis A vaccine in children ages 12 months to 15 years in healthy children ages 12 to 47 months.

Grazing collisions of black holes via the excision of singularities

We present the first simulations of non-head-on (grazing) collisions of binary black holes in which the singularities are excised from the simulation. Initially equal mass m black holes (spinning or not) are separated by approximately 10m and with impact parameter approximately 2m. Evolutions to t approximately 35m are obtained where two separate horizons are present for t approximately 3.8m; then a single enveloping horizon forms indicating that the holes merged. Apparent horizon area estimates suggest gravitational radiation of about 2%-3% of the total mass. The evolutions end after a moderate amount of time because of instabilities.

[Divided left atrium: operative results and follow-up in the cor triatriatum]

INTRODUCTION AND OBJECTIVES

A divided left atrium because of cor triatriatum is a relatively rare cardiac anomaly requiring corrective surgery. We describe here our clinical and surgical experience with this congenital heart defect as well as the different medium and long term diagnostic, surgical and evolution aspects.

PATIENTS AND METHODS

From 1981 to 1999, 15 children with cor triatriatum without complex associated cardiovascular defects underwent surgery at a mean age of 13 months (excision of the obstructive membrane). The surgical reports were reviewed and the clinical and echocardiographic data were analyzed before and after the intervention; six of these patients (40%) were referred to operating room only with the 2-D echo Doppler technique and color flow mapping information. The follow-up period ranged from 8 months to 19.3 years.

RESULTS

Diagnosis was confirmed during the surgical procedure. One 9 month old patient died 60 days after a successful corrective surgery because of sepsis (7%). No late deaths or reoperations were found in the follow-up period. All 14 patients who survived the operation have a functional class I (NYHA), and they are asymptomatic in the follow-up. The overall survival rate was 93% (70% CI: 87-90).

CONCLUSIONS

Corrective surgery with excision of the obstructive membrane dividing the left atrium restores normal anatomic, hemodynamic and clinical status in children with cor triatriatum without complex associated defects.