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(Lancet. 2023;402:386–396)Pre-eclampsia is a relatively common condition and poses a disproportionately high risk to women in low-income and middle-income countries where it is a leading cause of maternal morbidity and mortality, estimated to have caused more than 42,000 deaths. The only known treatment is delivery, but there are also risks associated with preterm delivery that can contribute to both maternal and neonatal outcomes. Evidence suggests delivery at 37 weeks optimizes outcomes for both mother and infant, but there is little evidence about delivery in the late preterm gestational period leading up to that, between 34 and 36 and 6/7 weeks. Research in higher income settings has shown that fetal death in these cases is rare, but there are factors in such settings that are unavailable or unrealistic in low-income and middle-income settings. This study aimed to address the gap in knowledge by assessing outcomes related to planned delivery between 34 and 37 weeks in women with pre-eclampsia compared with expectant management during the same gestational period in India and Zambia.

Reductions in circulating estradiol concentrations could be implicated in the pathogenesis of steroid-induced osteoporosis (SIOP) in men. We assessed serum estradiol and adrenal androgens (dehydroepiandrosterone sulfate [DHEAS] and androstenedione) in 77 men (group A: idiopathic osteoporosis [IOP], n = 38, aged [mean [plusmn] SD] 57.7 [plusmn] 12.1 years; group B: SIOP, n = 39, aged 55.3 [plusmn] 13.1 years). We also studied the relationship between bone mineral density (BMD) and serum estradiol in the group of men with SIOP. In group B, we observed a higher prevalence of low serum testosterone concentrations ([lt ]9.0 nmol/L) (P= .0052), which was significantly correlated with steroid dosage (r= [minus ]0.42, P= .0089) and estradiol concentrations (r= 0.42, P= .012). There was a significant positive association between BMD at the lumbar spine and serum estradiol (P= .004) in the men with SIOP (group B). A high proportion of subjects had low serum estradiol concentrations ([lt ]48 pmol/L) in both groups (group A: 44.7 %, group B: 36 %). Serum adrenal androgens concentrations were also significantly suppressed in group B (serum androstenedione[mdash ]group A: 4.99 [plusmn] 1.8; Group B: 2.1 [plusmn] 1.6 nmol/L; P= .0001). Serum DHEAS was undetectable in 59% of patients in group B versus 6% in group A (P= .001). Reductions in androstenedione also correlated with steroid dosage (r= [minus ]0.35, P= .01). In conclusion, the data show that adrenal androgens synthesis is markedly suppressed in men with SIOP. The clinical relevance of this finding remains to be determined. This study also shows a positive association between serum estradiol and BMD and a high prevalence of low serum estradiol in men with SIOP. Low serum estradiol may contribute to bone loss in men with SIOP.

Renal osteodystrophy is an important complication in patients with end-stage renal disease on maintenance dialysis. The aim of this study was to compare the biochemical markers of bone formation (serum collagen type I C-terminal propeptide) and resorption (serum deoxypyridinoline – DPD – and pyridinoline – PYR) with the bone mineral density (BMD) at lumbar spine, femoral neck, and forearm in patients with end-stage renal disease on haemodialysis (HD) versus continuous ambulatory peritoneal dialysis (CAPD). Fifty-nine adult patients, 45 on CAPD (18 females, 27 males) and 14 on HD (2 females, 12 males), were studied. The mean age was 44 ± SEM 1.6 and 54.4 ± 4.8 years, respectively. No significant differences in serum calcium, phosphorus, creatinine, and parathyroid hormone were found between patients on HD and CAPD in predialysis samples. Serum urea was significantly lower (p = 0.02) in the CAPD group. Serum PYR (nmol/l) and DPD (nmol/l) were significantly higher in patients on HD as compared with those on CAPD: 105 ± 23.3 versus 43.7 ± 3.47 (p = 0.007) and 31.0 ± 2.4 versus 24.4 ± 1.4 (p = 0.027), respectively. The results were still significantly higher in the HD patients following correction for serum creatinine and body mass index. There was a close correlation between dialysate DPD and creatinine in both dialysis modalities (HD r = 0.9, CAPD r = 0.76). The clearance of DPD did not differ significantly between the CAPD membrane and the HD membrane (p = 0.22). Serum collagen type I C-terminal propeptide was not significantly different between the HD and CAPD patients. The results were unaffected following correction for age and gender. The BMD was measured in 38 (65%) of the patients (HD n = 8, CAPD n = 30) by dual-energy X-ray absorptiometry and expressed as ‘Z’ scores. This was reduced at all sites in the patients with end-stage renal disease. The BMD was significantly lower at the ultradistal forearm (mostly trabecular bone) in HD patients as compared with CAPD patients (n = 0.02). A similar trend was observed at the lumbar spine, although the results failed to reach significance. In the whole population (n = 38), linear regression analysis revealed a significant negative correlation between BMD at the ultradistal forearm and serum PYR (r = –0.35, p = 0.04) and DPD (r = –0.33, p = 0.049). Combined measurements of BMD and biochemical markers of bone resorption may have potential in the identification of patients at high risk of bone loss who may require further evaluation of bone remodeling by bone histomorphometry.

Aortocaval compression may not be completely prevented by the supine wedged or tilted positions. It is commonly believed, however, that the unmodified full lateral position after induction of spinal anaesthesia might allow excessive spread of the block. We therefore compared baseline arterial pressures in the supine wedged, sitting, tilted and full lateral positions in 40 women who were about to undergo elective caesarean section. They were then given spinal anaesthesia in the left lateral position and randomised to be turned to the right lateral or the supine wedged position, after which speed of onset and spread of blockade to cold sensation were measured every 2 min for 10 min and mean arterial pressure and ephedrine requirement were recorded every minute for 20 min. Baseline mean arterial pressure was 9 mmHg (95% CI 3 to 14) lower in the left lateral (measured in the upper arm) than in the sitting position; those in the supine wedged and tilted positions were intermediate. Following spinal anaesthesia, hypotension (defined as a reading ≤80% of the baseline value in the same position) lasted 2.4 min longer (CI +0.6 to +4.1) in the supine wedged group, but there was no significant difference between the groups in maximum fall or ephedrine requirement. The upper level of block rose more rapidly in the supine wedged than in the lateral group and showed less variability. There is therefore no reason to fear the unmodified lateral group position, which may offer better protection against hypotension.

Background:A radiofrequency-controlled electrosurgical device (ESD) has been adapted for skin peeling. A high-voltage, low-amperage current converts an irrigant into an ionized vapor, causing molecular dissociation and superficial damage in adjacent tissue. Objective:We compared the clinical and histologic effects of a scanning carbon dioxide (CO2) laser (ESC/Sharplan 40C) and the ESD (Visage Cosmetic Surgery System, Arthrocare). Methods:This study was a matched clinical trial involving 9 subjects. Two strips (2 × 1 cm) of skin on the temple were alternately assigned to receive 2 passes with either the CO2laser (Silktouch mode, 260 handpiece, fluence 15 J/cm2, 10 mm2) or the ESD (125 V = setting 4, 5 mm handpiece). Strips were wiped with moist gauze after the first pass, and 4-mm punch biopsy specimens were taken immediately and after 3 months. Clinical assessment of re-epithelialization, erythema, and hyperpigmentation was made at 1, 2, 4, and 12 weeks. Results:Median erythema scores were significantly greater in skin treated with the CO2laser. Histologic examination showed greater epidermal loss and a significantly thicker zone of underlying thermal damage (average difference, 63 μm; 95% confidence interval, 40-87; P= .0002) in skin treated with the CO2laser compared with skin treated with the ESD. After 3 months, a band of superficial dermal fibrosis was thicker in skin treated with the CO2laser (average difference, 170 μm; 95% confidence interval, 69-271; P= .0075). Conclusion:Two passes with the ESD elicited a more superficial skin peel than the CO2laser. Despite minimal thermal damage, superficial dermal fibrosis was seen at 3 months in skin treated with the ESD. (J Am Acad Dermatol 2001;44:492-6.)

Concern has been expressed that recent changes in techniques of spinal blockade may have resulted in an increase in frequency of neurological sequelae. In order to make preliminary enquiries about anaesthetists’ recent experiences of neurological sequelae following spinal and combined spinal-epidural anaesthesia, a questionnaire, covering numbers of procedures, needles used and any neurological problems that had been encountered, was sent to the anaesthetist in charge of each obstetric centre on the Royal College of Obstetricians and Gynaecologists’ United Kingdom list. Replies were received from 222 of the 259 units, of whom 40 reported a total of 56 cases involving prolonged neurological sequelae, of which nine were probable obstetric palsies, 18 could be attributed to the regional procedure (one instance of conus damage and the rest largely sensory disturbances) and 29 were of uncertain origin, including a second conus damage. There was no obvious difference in incidence of problems associated with combined spinal-epidural vs. the single-shot spinal technique (odds ratio 1.14, confidence interval 0.53 to 2.46), or Sprotte vs. Whitacre atraumatic needle (odds ratio 1.40, confidence interval 0.64 to 3.08). A prospective survey, or better still, randomisation would be needed to verify these findings.

Background: Photodynamic therapy (PDT) has not been compared with topical 5-fluorouracil (5-FU) in the treatment of epidermal dysplasia. Objective: The purpose of this study was to assess the efficacy and tolerability of these two treatment modalities in 17 patients with actinic keratoses on the backs of the hands. Methods: Each patient's right and left hands were randomized to receive either a 3-week course of topical 5-FU applied twice per day or PDT using topical 5-aminolevulinic acid (5-ALA) and then, after 4 hours, irradiation with an incoherent light source consisting of a 1200 W metal halogen lamp emitting red light (580 to 740 nm). Each hand randomized for PDT received 150 J/cm^2. The observed median fluence rate was 86 mW/cm^2 (interquartile range, 53 to 100 mW/cm^2). All patients were reviewed at 1, 4, and 24 weeks after starting treatment. Results: Fourteen of 17 patients (82%) completed the study. The mean lesional area treated with topical 5-FU decreased from 1390 mm^2 (standard deviation [SD], 1130) to 297 mm^2 (SD, 209). This represents a mean reduction in lesional area of 70% (confidence interval [CI], 61%-80%). The mean lesional area treated with topical PDT decreased from 1322 mm^2 (SD, 1280) to 291 mm^2 (SD, 274), representing a mean reduction in lesional area of 73% (CI, 61%-84%). The reduction in lesional area elicited by the two treatment methods was similar (CI, -25% to 17%). There was no statistically significant difference between the treatment methods in overall symptom scores for pain and redness. Conclusion: One treatment with PDT using topical 5-ALA appears to be as effective and well tolerated as 3 weeks of twice-daily topical 5-FU, a cheap and widely available alternative. (J Am Acad Dermatol 1999;41:414-8.)

Background: Previous studies defining the clinical features of patients with chronic idiopathic urticaria (CIU) were performed before the identification of functional autoantibodies against Fc@eRI and/or IgE, now known to be present in approximately 30% of patients with CIU. Objective: Our purpose was to determine whether there are differences between patients with and those without autoantibodies in the clinical features or severity of CIU. Methods: The clinical features of 107 patients with CIU were evaluated prospectively. Patients were identified as having functional autoantibodies on the basis of the serum-evoked histamine release in vitro from the basophils of 2 healthy donors. Results: Patients with autoantibodies (31%) had more wheals (P = .005), a wider distribution of wheals (P = .009), higher itch scores for the most severe episodes of itching (P = .002), more systemic symptoms (P = .03), and lower serum IgE levels (P < .0005) than patients without autoantibodies. Conclusion: The presence of autoantibodies indicates a subset of patients with more severe CIU. (J Am Acad Dermatol 1999;40:443-50.)

(Acta Obstet Gynecol Scand. 2019;98:1178–1186)Almost half of annual maternal deaths can be attributed to postpartum hemorrhage (PPH), maternal sepsis, and abortion complications. Most of these deaths are avoidable with early identification of hemodynamic compromise, but many care providers lack the adequate training to respond properly to abnormal blood pressure (BP) and heart rate (HR) measurements. The ratio of HR to systolic BP, called the shock index (SI), is believed to be an early indicator of life-threatening adverse outcomes; SI has predicted medical events more consistently than other vital signs in PPH retrospective cohorts. While experts have proposed the use of SI measurement thresholds as early warning signs, more research is needed in PPH and maternal sepsis populations. These investigators conducted their study to determine whether SI can consistently predict adverse outcomes in PPH and maternal sepsis cases, and also observe if previously determined SI thresholds are adequate.

Background: Although it is widely assumed that dehydration predisposes to venous thromboembolism (VTE), there are no clinical studies to support this. Aim: To evaluate the relationship between biochemical indices of dehydration and VTE after acute ischaemic stroke (AIS). Design: Prospective observational study. Methods: Unselected AIS patients (n = 102) receiving standard thromboprophylaxis with aspirin and graded compression stockings, underwent serial measurements of serum urea, creatinine and osmolality, and were screened for VTE using magnetic resonance direct thrombus imaging. Results: Serum osmolality of >297 mOsm/kg, urea >7.5 mmol/l and urea:creatinine ratio (mmol:mmol) >80 a few days post-AIS were associated with odds ratios for VTE of, respectively, 4.7, 2.8 and 3.4 (p = 0.02, 0.05, 0.02) on multivariable analysis. Discussion: Dehydration after AIS is strongly independently associated with VTE, reinforcing the importance of maintaining adequate hydration in these patients.