One hundred ninety-four patients with cryptococcal meningitis were enrolled in a multicenter, prospective, randomized clinical trial to compare the efficacy and toxicity of four as compared with six weeks of combination amphotericin B and flucytosine therapy. Among 91 patients who met preestablished criteria for randomization, cure or improvement was noted in 75 percent of those treated for four weeks and in 85 percent of those treated for six weeks. The estimated relapse rate for the four-week regimen was higher--27 as compared with 16 percent--whereas the incidence of toxic effects for the two regimens was similar--44 as compared with 43 percent. Among 23 transplant recipients, 4 of 5 treated for four weeks relapsed, leading to the decision to treat the rest of the group for six weeks. Only 3 of the 18 treated for six weeks relapsed. In a third group of 80 patients, the protocol was not followed during the initial four weeks, and these patients were not randomized. Thirty-eight died or relapsed. Multifactorial analysis of pretreatment factors for all 194 patients identified three significant predictors (P less than 0.05) of a favorable response: headache as a symptom, normal mental status, and a cerebrospinal fluid white-cell count above 20 per cubic millimeter. These and other findings in this study are consistent with the view that the four-week regimen should be reserved for patients who have meningitis without neurologic complications, underlying disease, or immunosuppressive therapy; a pretreatment cerebrospinal fluid white-cell count above 20 per cubic millimeter and a serum cryptococcal antigen titer below 1:32; and at four weeks of therapy, a negative cerebrospinal fluid India ink preparation and serum and cerebrospinal fluid cryptococcal-antigen titers below 1:8. Patients who do not meet these criteria should receive at least six weeks of therapy.
This retrospective cohort study compared obstetrical outcomes in the pregnancy following an intrauterine death with those following a live birth in the first pregnancy in Scottish women having their first and second deliveries in the years 1976 to 2006. A total of 364 women having an intrauterine death in their first pregnancy constituted the "exposed" cohort. The nonexposed cohort, with an initial live birth, totaled 33,715 women. Ages were comparable in the 2 groups, but the stillbirth group had a higher median body mass index and were less likely than the unexposed group to be married or cohabiting. Exposed women were much likelier than those in the comparison group to be smokers.Exposed women were at an increased risk of both preeclampsia (adjusted odds ratio [OR], 3.1; 95% confidence interval [CI], 1.7-5.7) and placental abruption (adjusted OR, 9.4; 95% CI,. Induction of labor and instrumental delivery both were more frequent in exposed women, as were elective and emergency cesarean deliveries. For elective cesarean delivery the OR was 3.1, and the 95% CI was 2-4.8. Malpresentation, prematurity (birth at less than 37 weeks' gestation), and low birth weight all were more likely in the exposed cohort. The adjusted OR for stillbirth was 1.2, with a 95% CI of 0.4-3.4. Although stillbirths occurred in 1.4% of the exposed group and 0.5% of the comparison group, the difference was not statistically significant when adjusted for confounding factors.These findings indicate that intrauterine fetal death increases the risk of obstetrical and perinatal complications in a subsequent pregnancy. In the absence of known risk factors, however, the risk of a second stillbirth is not significantly increased. ABSTRACTCommunity-associated strains of methicillin-resistant Staphylococus aureus (MSRA) have occurred in outbreaks of infection in newborn nurseries, and they also are an emerging problem for pregnant women. Among the common sites of infection are the breast, buttocks, vulva, and groin. This study sought to determine whether genital tract colonization by MRSA in third-trimester women is associated with early-onset invasive infection by MRSA in newborn infants. 284Obstetrical and Gynecological Survey Preconception and Prenatal Care 285ABSTRACT Injury to the anal sphincter during childbirth is accepted as a major risk factor for fecal incontinence in women. As many as 50% of women with such injury report fecal incontinence, due mainly to a persistently defective sphincter. Risk factors for anal sphincter injury during operative vaginal delivery were examined in a population-based observational study of 7478 Management of Labor, Delivery, and the Puerperium 287 288 Obstetrical and Gynecological Survey tect the anal sphincter. Properly done, I would bet that it does. However, the retrospective nature of the study limits its value. A well-done study could move us from the present situation of technique based on habit and custom to technique based on evidence.-DJR) ABSTRACTProlonged episodes of labor induction or augmentation ...
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