Two-year infant neurodevelopmental outcome after single or multiple antenatal courses of corticosteroids to prevent complications of prematurity

OBJECTIVE

This study was undertaken to evaluate the effect of exposure to multiple antenatal steroid courses on short-term neonatal morbidity and 2-year infant neurodevelopmental outcome.

STUDY DESIGN

This was a prospective observational study of 201 preterm singleton infants who received 1 or more courses of corticosteroids to prevent complications of prematurity and were delivered between 24 and 34 weeks' gestation at a single institution. Neurodevelopmental outcome of the infants was evaluated at 2 years corrected age. Logistic regression analysis was used to perform multivariate analyses of associations and trends.

RESULTS

One hundred thirty-eight subjects (68.7%) received at least 1 complete course of betamethasone, whereas 63 (31.3%) patients were treated with dexamethasone. The prevalence of multiple steroid doses exposure was 26.8% (37/138) in betamethasone and 52.4% (33/63) in dexamethasone group. The prevalence of infant leukomalacia, including both prolonged echogenicity and cystic leukomalacia, was 25.9% (34/131) after a complete corticosteroid course, 40% (6/15) after 1, 42.3% (12/28) after 2, and 44.4% (12/27) after more than 2 additional courses, respectively (adjusted P for trend=.011). In the same categories of steroid exposure, the corresponding prevalences of 2-year infant neurodevelopmental abnormalities were 18% (20/111), 21.4% (3/14), 29.2% (7/24), and 34.8% (8/23), respectively (adjusted P for trend=.038). Multivariate study of first grade interaction suggested that the risk of leukomalacia and 2-year infant neurodevelopmental abnormalities associated with multiple doses exposure was confined to dexamethasone. In fact, compared with betamethasone, exposure to multiple doses of dexamethasone was associated with an increased risk of leukomalacia (19/33 compared with 11/37; odds ratio [OR]=3.21, 95% CI=1.07-9.77) and overall 2-year infant neurodevelopmental abnormalities (12/28 compared with 6/35; OR=3.63, 95% CI=1.03-13.58).

CONCLUSION

In this study, multiple antenatal courses of dexamethasone but not betamethasone were associated with an increased risk of leukomalacia and 2-year infant neurodevelopmental abnormalities.

Short esophagus: literature incidence

There are controversies regarding existence and incidence of short esophagus. The authors reviewed the literature incidence of short esophagus among operated patients due to gastroesophageal reflux disease in the last 3 years. The overall incidence of short esophagus was 1.53%. The proposed risk factors (paraesophageal hernia, Barrett's esophagus, reoperation, esophageal strictures and access route) do have a higher incidence of short esophagus, with the exception of the Barrett's esophagus. Although several biases can be associated with the review, the authors identified the short esophagus incidence in the literature.

Efficacy of mediastinal lymphadenectomy in transhiatal esophagectomy with and without diaphragm opening: a cadaveric study

Transhiatal esophagectomy (THE) is believed to induce a lower morbidity and mortality compared with transthoracic esophagectomy, but to be inefficient in performing mediastinal lymphadenectomy. Some surgeons are convinced that lymphadenectomy of the lower mediastinum in THE and transthoracic esophagectomy are equivalent. To test this, the authors performed THE in 20 cadavers (10 with and 10 without diaphragm opening). The number of lymph nodes resected with the esophagus and dissected through the hiatus was counted. After THE, the thorax was opened and the number of residual lymph nodes was evaluated. Complications were also assessed. The results show that lymphadenectomy in THE is incomplete in the lower mediastinum and not possible in the upper mediastinum; comparing THE with and without diaphragm opening, the first permits resection of a superior number of lymph nodes with the esophagus and dissection of a higher number of nodes through the hiatus. It is concluded that THE does not provide an effective mediastinal lymphadenectomy.

Laparoscopy predicts metastatic disease and spares laparotomy in selected patients with pancreatic nonfunctioning islet cell tumors

INTRODUCTION

Our objective was to compare the efficacy of CT alone to CT followed by laparoscopy in determining resectability of pancreatic nonfunctioning islet (NFI) cell tumors.

METHODS

A retrospective analysis from 1993 to 1999 revealed 48 patients who underwent surgical evaluation for NFI cell tumors. Of these, 34 (71%) patients underwent laparoscopy and CT for either diagnostic purposes or tumor staging. CT and laparoscopic criteria for curative resectability were defined and the sensitivity, specificity, and predictive value of both modalities in determining resectability were calculated.

RESULTS

The most frequent tumor location and presenting symptoms were pancreatic head (n = 27, 56%) and abdominal pain (n = 31, 65%), respectively. Median tumor size was 4.0 cm. In the laparoscopy group, curative resection was performed in 20 cases (59%). CT followed by laparoscopy was more sensitive than CT alone in predicting resectability (93% vs. 50%, P = 0.03) with similar specificity (both 100%). The predictive value for tumor resectability was 74% for CT alone and 95% for CT followed by laparoscopy. Reasons for unresectability identified at laparoscopy but not indicated by CT were liver metastases (n = 6) or nodal disease (n = 1). Four of these patients were spared a laparotomy while the other three patients underwent surgical palliation and all are alive with disease (AWD). In those not undergoing laparoscopy (n = 14), curative resection was performed in 64% (n = 9). Four of these patients underwent resection, despite having metastases, and three are AWD.

CONCLUSIONS

NFI cell tumors of the pancreas present as large masses with frequent metastases. Despite metastatic disease, prolonged survival is often achieved with or without open surgical treatment. Laparoscopy can be used in diagnosis and accurately identifies metastases not seen on CT, thus sparing laparotomy in some patients.

Uterine myoma in postmenopause: a comparison between two therapeutic schedules of HRT

OBJECTIVES

It is still controversial whether hormone replacement therapy (HRT) can affect the onset of uterine myomas or their growth in postmenopause. It is likely that some therapeutic schedules can influence the myometrial growth differently, due to a more potent stimulation of the uterine receptors. The aim of the present study is to evaluate the effects of two different hormonal treatment schedules on the risk of uterine myoma onset or progression.

METHODS

In a 2 year prospective randomised study we compared an oral cyclic association of oestradiol valerate and cyproterone acetate versus a sequential combination of transdermal E(2) and per oral medrossiprogesterone acetate on 240 postmenopausal women with and without uterine myomas.

RESULTS

Among the patients without uterine myomas treated with the transdermal-oral combination we noted the onset of myomas in 5% of cases after 24 months of treatment, while no new uterine formation was observed for the orally treated women (P<0.01). Among the patients with uterine myomas at the beginning of the study, in the group transdermally treated we found a mean increase in myoma volumes of 25.3% in the following 24 months, which was significantly different compared with the initial volume of myomas. On the other hand, women treated with the oral combination showed no significant modification of myoma volumes at the end of the study.

CONCLUSIONS

Percutaneous-oral schedule of HRT seems to affect the growth of uterine myomas more than a single oral combination of oestradiol valerate and cyproterone acetate.

Vertical transmission of hepatitis C virus and follow-up of newborns from infected mothers

BACKGROUND

Aim of the study is to analyze the rate of vertical transmission of HCV and the time of clearance of maternal antibodies in non-infected babies serum.

METHODS

We have studied 36 babies born to HCV-positive and HIV-negative pregnant women at the University of Pavia. All mothers underwent blood tests to evaluate the presence of anti-HCV antibodies and viral RNA during pregnancy and after delivery. All babies underwent several tests at different times to evaluate the presence of viral RNA and the clearance of maternal antibodies.

RESULTS

All babies proved HCV-Ab positive at birth, but only one case (2.7%) proved infected at PCR analysis. Different patterns of HCV-Ab clearance were noted in the 35 non-infected babies. Of 24 babies from HCV-RNA-positive mothers, HCV-Ab reached zero in 24 months while in 11 babies from HCV-RNA-negative mothers, the antibodies disappeared at 12 months. A statistical difference was noted between the two groups of babies for the time of clearance of antibodies.

CONCLUSIONS

The risk of vertical transmission in babies born to HCV-RNA negative mothers is very low, and the clearance of maternal antibodies is set within 12 months of follow-up. Mothers positive to HCV-RNA have a higher risk of transmitting the virus to their offspring and the time of clearance of antibodies in non-infected babies seems to be longer. A correct follow-up of these children must be no shorter than 24 months.

Bone mineral changes during and after lactation

OBJECTIVE

To investigate variations in bone mineral density during lactation and throughout the 12 months after scheduled cessation of lactation in relation to the resumption of ovarian function.

METHODS

Three hundred eight mothers who decided to lactate were scheduled to fully breast-feed for 6 months, followed by a 1-month weaning period, and then suppress lactation with cabergoline. Their bone mineral density variations were compared with those of a control group of nonlactating mothers during the first 18 months postpartum. Half the lactating women were given daily oral calcium supplements of 1 g in an open design.

RESULTS

There was a significant progressive decrease in bone mineral density in lactating women over the first 6 months, followed by recovery of bone mass up to levels that at 18 months were higher than baseline. In nonlactating women, bone mineral density increased progressively after delivery, and at 18 months postpartum had increased by 1.1-1.9% compared with baseline. Compared with lactating women who resumed menstruation within 5 months of delivery, breast-feeding mothers with longer amenorrhea initially lost more bone, but they also gained significantly more bone after resumption of menses, so there were no differences at 18 months postpartum. Oral calcium supplementation decreased bone loss, but had only a transient effect.

CONCLUSION

A scheduled lactation period of 6 months, followed by a 1-month weaning period, allowed bone mineral density to reach higher values compared with early postpartum, regardless of calcium supplementation and duration of postpartum amenorrhea.

Long-term sequential treatment with combined estradiol valerate and cyproterone acetate in early postmenopause

BACKGROUND

We sought to evaluate the long-term safety and efficacy of cyclic combined estradiol valerate and cyproterone acetate.

METHODS

A six-year, single center, open study was performed of forty-eight recently postmenopausal women. We evaluated biochemical markers of bone turnover, bone mineral content, bone mineral density, serum lipids, climacteric symptoms, and bleeding throughout the six-year period. Ultrasound evaluation of the endometrium was performed yearly for the first two years.

RESULTS

Markers of bone turnover were decreased over the study period, while bone mineral content and density remained unchanged. High density lipoprotein cholesterol levels were increased with unchanged blood pressure over the six years. Menopausal symptoms showed significant improvements within 6 months. Endometrial scan results never required hysteroscopic evaluation.

CONCLUSION

Sequentially combined estradiol valerate and cyproterone acetate can be used for an indefinite number of years in women with recent natural menopause. Cyproterone acetate provides adequate endometrial protection and cycle control while allowing estradiol valerate to exert its positive effects on lipid profile, bone metabolism, and climacteric symptoms.

DR antigen expression on ovarian carcinoma cells does not correlate with their capacity to elicit an autologous proliferative response

Expression of HLA-DR antigens by purified preparations of human ovarian carcinoma cells freshly isolated from surgical specimens was examined in parallel with the capacity of tumor cells to elicit a blastogenic response from autologous lymphocytes in mixed lymphocyte-tumor culture (MLTC) assay. Of 21 tumor preparations, 11 (52%) reacted with monoclonal antibodies 279 and/or 949 specific for a monomorphic determinant of HLA-DR antigens, with heterogeneous positivity, ranging between 30% and 95%. In this series of patients positive MLTC occurred in 8/21 individual experiments. The HLA-DR expression was proportionally similar in tumors giving positive MLTC (4/8 = 50%) and negative MLTC (7/13 = 53%). The lack of correlation between DR expression on tumor cells and stimulatory activity in autologous MLTC and the fact that DR-negative tumors could induce lymphocyte stimulation, support the hypothesis that blastogenesis occurs upon recognition of tumor-associated antigens, different from DR molecules, possibly tumor-specific antigens.