Pregnancy outcomes for women with placenta previa in relation to the number of prior cesarean deliveries

OBJECTIVE: To estimate the association between the number of prior cesarean deliveries and pregnancy outcomes among women with placenta previa. METHODS: Women with a placenta previa and a singleton gestation were identified in a concurrently collected database of cesarean deliveries performed at 19 academic centers during a 4-year period. Maternal and perinatal outcomes were analyzed after stratifying by the number of cesarean deliveries before the index pregnancy. RESULTS: Of the 868 women in the analysis, 488 had no prior cesarean delivery, 252 had one prior cesarean delivery, 76 had two prior cesarean deliveries, and 52 had at least three prior cesarean deliveries. Multiple measures of maternal morbidity (eg, coagulopathy, hysterectomy, pulmonary edema) increased in frequency as the number of prior cesarean deliveries rose. Even one prior cesarean delivery was sufficient to increase the risk of an adverse maternal outcome (a composite of transfusion, hysterectomy, operative injury, coagulopathy, venous thromboembolism, pulmonary edema, or death) from 15% to 23%, which corresponded, in multivariable analysis, to an adjusted odds ratio of 1.9 (95% confidence interval 1.2-2.9). Conversely, gestational age at delivery and adverse perinatal outcome (a composite measure of respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage grade 3 or 4, seizures, or death) were unrelated to the number of prior cesarean deliveries. CONCLUSION: Among women with a placenta previa, an increasing number of prior cesarean deliveries is associated with increasing maternal, but not perinatal, morbidity. LEVEL OF EVIDENCE: II.     

Plasma levels of interleukin-18 and interleukin-18 binding protein are elevated in patients with chronic liver disease

Interleukin 18 (IL-18) is a recently described proinflammatory cytokine. In mouse models it has been shown to play a key role in the development of liver injury. IL-18 binding protein (IL-18BP) is a naturally occurring antagonist of IL-18. In this study we investigated whether IL-18/IL-18BP levels are altered in patients with chronic liver disease (CLD). We measured IL-18 and IL-18BP plasma levels in 153 patients with CLD and 41 healthy controls by a specific ELISA. Plasma levels of IL-18 were significantly higher in CLD patients than in healthy controls. Cirrhotics had higher levels than noncirrhotics. IL-18 levels increased with disease progression. IL-18BP plasma levels paralled the increase of IL-18 with disease progression, except in stage Child C cirrhosis. IL-18 and IL-18BP levels were elevated independent of the etiology of CLD. IL-18 and IL-18BP correlated with laboratory parameters of inflammation and liver injury. Plasma levels of IL-18 and its antagonist, IL-18BP, are elevated in CLD and correlate with severity of disease. IL-18BP may not be sufficient to counteract the overwhelming proinflammatory response in end stage liver disease.     

Morphological and Quantitative Study of the Myenteric Plexus in the Human Tenia Coli

The longitudinal muscle in the large intestine in humans and some other mammalian species is concentrated in regions known as “tenia coli.” The myenteric plexus under the tenia is believed to be highly developed to control the adjacent large muscle mass, however, data on the innervation of this region are very scarce. We used whole mount preparations of human colon to characterize the organization of the myenteric plexus under the tenia coli (UT) and compared it with the plexus between the tenia (BT). Using histochemical staining for NADPH diaphorase, we found that the meshwork UT was 50% denser than BT, and that the ganglia UT were 30% wider. The density and size of the NADPH‐d positive neurons UT were similar to those of BT. We conclude that the myenteric plexus UT is considerably more developed than BT, and suggest to understand the control of colonic motility, the myenteric plexus UT needs to be further investigated. Anat Rec, 2012. © 2012 Wiley Periodicals, Inc.     

Risk-adapted BEACOPP regimen can reduce the cumulative dose of chemotherapy for standard and high-risk Hodgkin lymphoma with no impairment of outcome

Therapy of Hodgkin disease (HD) is designed to prolong progression-free survival and minimize toxicity. The best regimen to achieve this has not yet been defined. A total of 108 patients with newly diagnosed HD and adverse prognostic factors were prospectively studied between 1999 and 2004. They were assigned to therapy according to defined risk stratification. Patients were defined depending on the International Prognostic Score (IPS). Those with IPS of 3 or higher received 2 cycles of escalated therapy, including bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPP [EB]). All others received 2 cycles of standard BEACOPP (SB). Subsequent therapy was prospectively assigned following 2 cycles according to results of early interim 67Ga or positron emission tomography/computed tomography (PET/CT). Following a positive interim scan, 4 cycles of EB were administered, whereas 4 cycles of SB were given to patients with a negative scan. The complete remission rate, the 5-year event-free survival (EFS), and overall survival (OS) rates were 97%, 85% and 90%, respectively. Relapse or progression occurred in 27% of patients with interim positive PET/CT versus 2.3% of negative scans (P<.02). Early interim fluorine-18 2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT is a useful tool for adjustment of chemotherapy on an individual basis. Similar EFS and OS rates were observed for patients in both risk groups.     

Treatment of glucocorticoid-resistant or relapsing takayasu arteritis with methotrexate

Objective. To identify the role of methotrexate (MTX) in the treatment of persistent or recurrent Takayasu arteritis that is refractory to treatment with glucocorticoids (GC) alone. Methods. An open-label pilot study of weekly low-dose MTX + GC treatment was performed. Outcome was evaluated according to clinical characteristics, laboratory abnormalities, findings on routinely performed angiographic studies, and ability to withdraw GC and MTX therapy. Eighteen patients entered the study; 2 dropped out, and 16 were followed up for a mean period of 2.8 years (range 1.3–4.8 years). Results. Weekly administration of MTX (mean stable dose of 17.1 mg) and GC resulted in remissions in 13 of 16 patients (81%). However, 7 patients (44%) had relapses as GC was tapered to or near discontinuation. Retreatment again led to remission, and 3 of 7 patients in this group have successfully stopped GC therapy. Of those patients who achieved remission, 8 (50%) have sustained remissions of 4–34 months (mean 18 months), and 4 of this group have not required GC or MTX therapy for 7–18 months (mean 11.3 months). Three patients experienced disease progression in spite of treatment. Conclusion. About half of all Takayasu arteritis patients have chronic active disease for which GC therapy alone does not provide sustained remissions that allow withdrawal of treatment. Weekly low-dose MTX is an effective means of inducing remission and minimizing GC therapy and toxicity in most of these patients. Further long-term studies will be required to assess the durability of remission and the need for maintenance MTX therapy in this subset of Takayasu arteritis patients.