Diverticular Disease: Electrophysiologic Study and a New Concept of Pathogenesis

The cause of diverticular disease (DD) is not exactly known, although colonic motor disorder has been proposed as a factor in the pathogenesis of the condition. We investigated the hypothesis that disordered colonic electrical activity is responsible for the colonic motor dysfunction and the development of DD. The electromyographic (EMG) activity and pressure of the sigmoid colon (SC) were recorded in 36 patients [16 early cases, 20 advanced cases; age (mean ± SD) 53.3 ± 5.6 years; 19 women, 17 men] and 22 healthy volunteers. The percutaneous route was used for recording the SC EMG. The healthy volunteers exhibited SC slow waves with a regular rhythm and the same frequency, amplitude, and conduction velocity from the three electrodes in the same subject. The SC basal pressure (7.9 cm H₂O) was interrupted by bouts of high pressure (26.8 cm H₂O). The early-DD cases showed slow waves with an irregular rhythm and significantly higher variables (p < 0.05) than the volunteers. Action potentials followed randomly or were superimposed on the slow waves. The SC basal pressure was significantly higher than that of the volunteers (21.4 cm H₂O, p < 0.01). Bouts of pressure (58.6 cm H₂O) coupled with action potentials were recorded. No waves were recorded from 15 of 20 of the advanced-DD patients. In 5 patients, slow waves with an irregular rhythm and lower variables (p < 0.05) than those of the volunteers were recorded. The basal SC pressure was significantly above normal. Three electrical activity patterns could be identified in DD patients: tachyrhythmic in the early-DD patients and bradyrhythmic or silent in the late-DD patients. These dysrhythmias may result from a disordered colonic pacemaker. The similarity between early DD and the irritable bowel syndrome suggests that DD is an advanced stage of the irritable bowel syndrome; studies are required to investigate this hypothesis further.     

Uterine contraction frequency before and after successful tocolytic therapy for preterm uterine contractions

OBJECTIVE: To examine the association between prelabor uterine contraction frequency (UCF) and the success of tocolytic therapy for preterm labor (PTL). STUDY DESIGN: Eleven centers conducted a prospective, observational study of UCF recorded between 22(0/7) and 36(6/7) weeks' gestational age or until delivery > or = 2 times/d on > or = 2 d/wk in women with singleton pregnancies with and without risk factors for preterm birth. Uterine contraction data obtained from patients diagnosed with PTL allowed comparison of mean UCF both before and after an acute episode of PTL treated with either intravenous, subcutaneous or oral tocolysis. The signed rank test was used to analyze differences in UCF before and after tocolytic therapy and between women who were or were not successfully treated with a labor-inhibiting agent. RESULTS: Of 454 enrolled women, 128 were diagnosed with PTL, and 74 were successfully treated with a labor-inhibiting agent. The mean UCF preceding PTL was not different between those women successfully treated and those who delivered as a consequence of the PTL episode. There was no difference (P = .653) in mean UCF between the week before PTL (UCF 0.60 +/- 0.8, median 0.30) and the first week of monitoring after successful tocolysis (UCF 0.82 +/- 1.4, median 0.27). CONCLUSION: The mean UCF immediately preceding PTL does not predict tocolytic success or failure.     

Chronic hypertension in pregnancy

Hypertension is the most common medical disorder during pregnancy. Chronic hypertension is a serious medical complication in pregnancy with increased maternal and perinatal morbidity and mortality. Those who develop uncontrolled severe hypertension, those with target organ damage, and those who are poorly compliant with prenatal visits are at high risk for poor perinatal outcome. Maternal complications include abruptio placenta, stroke, and superimposed pre-eclampsia. Fetal complications include prematurity, low birth weight, and perinatal death. Careful antepartum, intrapartum and postpartum management of women with high-risk chronic hypertension in pregnancies may reduce morbidity and mortality.     

Demographic and obstetric factors influencing pregnancy outcome in twin gestations

OBJECTIVE: Our purpose was to identify the influence of parity and previous preterm delivery on pregnancy outcome in twin gestations. STUDY DESIGN: A retrospective comparative analysis of women with twin gestations completing an outpatient preterm labor surveillance program between April 1995 and February 2000 was performed. Included were those enrolled at <24 weeks' gestation. Parity, maternal age, prepregnancy body mass index (BMI), cerclage, tocolytic use, and pregnancy outcome were identified. Data were divided into nulliparas, multiparas without previous preterm delivery, and those with previous preterm delivery. Analysis of variance and the Pearson chi2 test were used for statistical analysis. RESULTS: Data were analyzed for 1268 twin pregnancies. The mean gestational age at delivery for the multiparous women without a history of previous preterm delivery (35.3 +/- 2.7 weeks) was significantly greater than the mean gestational age at delivery for nulliparous (34.4 +/- 3.2 weeks) and multiparous women with a previous preterm delivery (34.0 +/- 3.1 weeks), P <.001. The greater gestational age at delivery in the multiparous women without a previous preterm delivery was associated with a significantly shorter newborn hospital stay and a lower need for mechanical ventilation use compared with the other groups (all P values < or =.001). CONCLUSION: In twin gestations, multiparous women without history of previous preterm delivery have a significantly greater gestational age at delivery, a lower incidence of cerclage, and a reduced neonatal hospital stay than do nulliparous women or those with a history of a previous preterm delivery.     

Increased risk of preeclampsia among nulliparous pregnant women with idiopathic hematuria

OBJECTIVE: Our purpose was to determine the risk of preeclampsia and gestational hypertension among nulliparous pregnant women with idiopathic hematuria. STUDY DESIGN: We conducted a prospective cohort study using data from the trial of Calcium for Preeclampsia Prevention (CPEP). Participants were followed up from screening and enrollment (gestational weeks 11-21) throughout pregnancy. Our analysis was limited to women who had been followed up to at least 20 weeks' gestation, had outcome information available, and were not suspected to have had urolithiasis. Surveillance for hematuria was conducted with dipsticks on clean-catch urine specimens obtained at research clinic visits. Idiopathic hematuria was defined as hematuria identified at regularly scheduled clinic visits in the absence of urinary tract infection and before the onset of labor. Logistic regression was used to estimate the risk of preeclampsia among women with hematuria compared with women without hematuria. RESULTS: Among the 4307 women available for analysis, 132 (3%) had idiopathic hematuria during pregnancy. Idiopathic hematuria was associated with an almost 2-fold increased odds for development of preeclampsia (adjusted odds ratio [aOR] = 1.89, 95% CI 1.12- 3.18) but not with increased odds of gestational hypertension (aOR = 0.78, 95% CI 0.46-1.32). CONCLUSIONS: Idiopathic hematuria identified during pregnancy is associated with greater risk of preeclampsia but not gestational hypertension.     

Prevalence and covariates of obesity in Lebanon: findings from the first epidemiological study

OBJECTIVE: To estimate the prevalence of overweight and obesity and examine associated covariates in the Lebanese population. RESEARCH METHODS AND PROCEDURES: A cross-sectional survey of a representative sample of 2104 individuals, 3 years of age and older. Anthropometric measurements and dietary assessments were conducted following standard methods and techniques. Overweight and obesity (classes I to III) were defined according to internationally standardized criteria for classification of BMI. RESULTS: For children 3 to 19 years of age, prevalence rates of overweight and obesity were higher overall for boys than girls (22.5% vs. 16.1% and 7.5% vs. 3.2%, respectively). For adult men and women (age > or = 20 years), the prevalence of overweight was 57.7% and 49.4%, respectively. In contrast, obesity (BMI > or = 30 kg/m(2)) was higher overall among women (18.8%) than men (14.3%), a trend that became more evident with increasing obesity class. BMI, percentage of body fat, and waist circumference increased to middle age and declined thereafter. Whereas lack of exercise associated significantly with obesity among children, obesity in older adults was more prevalent among the least educated, nonsmokers, and those reporting a family history of obesity. DISCUSSION: The results from this national population-based study in Lebanon show high prevalence rates of overweight and obesity comparable with those observed in developed countries such as the United States. While further studies are needed to examine the underlying social and cultural factors associated with lifestyle and nutritional habits, now is the time to institute multicomponent interventions promoting physical activity and weight control nationwide.     

Lack of association of severe preeclampsia with maternal and fetal mutant alleles for tumor necrosis factor alpha and lymphotoxin alpha genes and plasma tumor necrosis factor alpha levels

OBJECTIVE: The purpose of this study was to determine whether the increased frequency of mutant alleles of the gene for tumor necrosis factor alpha and elevated maternal and fetal plasma levels of tumor necrosis factor alpha were associated with severe preeclampsia. STUDY DESIGN: We performed a prospective cross-sectional study involving 112 patients with severe preeclampsia matched for gestational age with 106 normotensive pregnant women. Deoxyribonucleic acid for restriction fragment length polymorphism analysis was extracted from maternal and fetal blood. Two mutations associated with the gene for tumor necrosis factor alpha were assayed by polymerase chain reaction. Polymerase chain reaction products were digested with the restriction enzyme Ncol and then fractionated by gel electrophoresis. Genotypic frequencies were calculated. Maternal and fetal plasma tumor necrosis factor alpha levels were assayed by the dual monoclonal antibody sandwich enzyme-linked immunosorbent assay technique. The chi2 test, the Fisher exact test, the Student t test, and the Mann-Whitney test were performed to calculate statistical significance. RESULTS: The differences in the genotypic frequencies of the two loci were not significant in either maternal or fetal samples between control women and women with pregnancies complicated by severe preeclampsia. There was no statistical difference in median maternal plasma levels of tumor necrosis factor alpha between control subjects (0.0 pg/mL) and patients with severe preeclampsia (2.5 pg/mL; P =.36). Unexpectedly, fetal plasma tumor necrosis factor alpha levels were found to be significantly elevated in control women (18.4 pg/mL) relative to women with severe preeclampsia (9.1 pg/mL; P <.0001). CONCLUSION: Neither the genotypic frequencies for tumor necrosis factor alpha mutant alleles nor maternal tumor necrosis factor alpha plasma levels were increased in patients with severe preeclampsia.     

A comparison of various routes and dosages of misoprostol for cervical ripening and the induction of labor

OBJECTIVE: The purpose of this study was to compare the efficacy of different routes of misoprostol administration for cervical ripening and the induction of labor. STUDY DESIGN: Three hundred thirty women at > or = 32 weeks gestation with a Bishop score < or = 6 and an indication for induction were randomized to 1 of 3 double-blinded groups: (1) 25 microg orally administered misoprostol plus 25 microg vaginally administered misoprostol, (2) orally administered placebo plus 25 microg vaginally administered misoprostol, or (3) 25 microg orally administered misoprostol plus vaginally administered placebo. Doses were repeated every 4 hours until onset of labor or a maximum of 12 doses were given. The primary outcome of the trial was vaginal delivery within 24 hours of the initiation of induction. Secondary outcomes were the time from induction to delivery, need for oxytocin augmentation, mode of delivery, frequency of side effects, and neonatal and maternal outcome. Analysis of variance, chi-square test, and logistic regression were used for analysis. RESULTS: There were no significant differences in maternal characteristics or indications for induction. The percentage of women who achieved vaginal delivery within 24 hours was highest in the vaginally administered misoprostol group: 67% compared with 53% in the oral-plus-vaginal group (P < .05) and 36% in the oral group (P < .05). The median time to vaginal delivery was shorter in the vaginal and oral-plus-vaginal misoprostol groups, 13.5 hours and 14.3 hours, respectively, when compared with 23.9 hours in the oral group (P < .05). The rate of cesarean delivery was lowest in the vaginal misoprostol group (17% compared with 30% in the oral-plus-vaginal group and 32% in the oral group; P < .05). Uterine tachysystole occurred least frequently in the oral misoprostol group (10% compared with 32% in the vaginal group and 34% in the oral-plus-vaginal group; P < .05). Uterine hyperstimulation also occurred least frequently in the oral misopro-stol group (4% compared with 15% in the vaginal group and 22% in the oral-plus-vaginal group; P < .05). CONCLUSION: At the doses studied, induction of labor with vaginally administered misoprostol is more efficacious than either oral-plus-vaginal or oral-only route of administration.