A decision analysis of mandatory compared with voluntary HIV testing in pregnant women.

BACKGROUND: The benefit of antiretroviral therapy in reducing maternal-fetal transmission of HIV during pregnancy has caused a public policy debate about the relative benefits of mandatory HIV screening and voluntary HIV screening in pregnant women. OBJECTIVE: To evaluate the benefits and risks of mandatory compared with voluntary HIV testing of pregnant women to help guide research and policy. DESIGN: A decision analysis that incorporated the following variables: acceptance and benefit of prenatal care, acceptance and benefit of zidovudine therapy in HIV-infected women, prevalence of HIV infection, and mandatory compared with voluntary HIV testing. MEASUREMENTS: The threshold deterrence rate (defined as the percentage of women who, if deterred from seeking prenatal care because of a mandatory HIV testing policy, would offset the benefit of zidovudine in reducing vertical HIV transmission) and the difference between a policy of mandatory testing and a policy of voluntary testing in the absolute number of HIV-infected infants or dead infants. RESULTS: Voluntary HIV testing was preferred over a broad range of values in the model. At baseline, the threshold deterrence rate was 0.4%. At a deterrence rate of 0.5%, the number of infants (n = 167) spared HIV infection annually in the United States under a mandatory HIV testing policy would be lower than the number of perinatal deaths (n = 189) caused by lack of prenatal care. CONCLUSIONS: The most important variables in the model were voluntary HIV testing, the deterrence rate associated with mandatory testing compared with voluntary testing, and the prevalence of HIV infection in women of child-bearing age. At high levels of acceptance of voluntary HIV testing, the benefits of a policy of mandatory testing are minimal and may create the potential harms of avoiding prenatal care to avoid mandatory testing.

Method of delivery of the nonvertex second twin: a community hospital experience.

The purpose of this study is to examine the incidence of cesarean section and fetal distress complicating the delivery of the second twin in vertex-nonvertex twin gestations in which the second twin underwent either breech extraction or external version. The intrapartum courses of 510 twin gestations delivered at a community hospital over a 10-year period were retrospectively analyzed. All vertex-nonvertex twin gestations were identified in which the second twin underwent attempted breech extraction or external version. Exclusion criteria included birthweight < or = 1,500 g, fetal anomaly, intrauterine demise, and monoamniotic twins. Of the 76 twin sets that met inclusion criteria, 33 underwent external version and 43 underwent primary breech extraction. The two groups had similar demographic characteristics. External version compared to breech extraction was associated with a significantly greater incidence of cesarean section (8/33 vs. 1/43, P = .008) and fetal distress (8/33 vs. 1/43, P = .008). There was no difference between groups in neonatal outcome for the second twin as measured by length of stay, 5-minute Apgar < 7, intensive care unit admissions, hyaline membrane disease, intraventricular hemorrhage, and traumatic birth injury. In conclusion, the increased incidence of cesarean section and fetal distress in patients undergoing attempted external version suggests that breech extraction may be the preferable route of delivery for the nonvertex second twin weighing more than 1,500 g.

Emergent cervical cerclage: predictors of success or failure.

Emergent cervical cerclage is a procedure not commonly performed in general clinical practice. The outcome of pregnancies requiring emergent cerclage is based on limited information. The factors that predict success are not well known. Previous studies have suggested that advanced cervical dilation, significant cervical effacement, and the presence of prolapsed membranes are correlated with cerclage failure. We present a retrospective review of maternal characteristics predictive of perinatal survival. Analysis showed the presence of membrane prolapse to be the strongest predictor of poor outcome. Analysis also reveals a significant association between initial white blood cell count and perinatal outcome. This information may be helpful in decision making regarding adjunctive procedures such as amniocentesis and counseling patients regarding the likely outcome.

Treatment of recurrent eczema herpeticum in pregnancy with acyclovir.

BACKGROUND: Eczema herpeticum is an uncommon manifestation of an infection with herpes simplex virus (HSV). The disease is primarily seen in patients with histories of atopic eczema. Eczema herpeticum may be a life-threatening illness, but the mortality is felt to be <10% with modern antiviral and antibacterial agents. The use of acyclovir for other viral infections secondary to herpesvirus in pregnancy has been well documented. The authors now present a case report of eczema herpeticum treated with acyclovir during pregnancy. CASE: A patient with a history of eczema herpeticum presented in pregnancy with a recurrence. She was successfully treated with intravenous (IV) acyclovir with good maternal and fetal outcome. CONCLUSION: Acyclovir may be utilized in pregnancy for several manifestations of HSV including eczema herpeticum.

The bidirectional flux of cholesterol between cells and lipoproteins. Effects of phospholipid depletion of high density lipoprotein.

The bidirectional surface transfer of free cholesterol (FC) between Fu5AH rat hepatoma cells and human high density lipoprotein (HDL) was studied. Cells and HDL were prelabeled with [4-14C]FC and [7-3H]FC, respectively. Influx and efflux of FC were measured simultaneously from the appearance of 3H counts in cells and 14C counts in medium. Results were analyzed by a computerized procedure which fitted sets of kinetic data to a model assuming that cell and HDL FC populations each formed a single homogeneous pool and that together the pools formed a closed system. This analysis yielded values for the first-order rate constants of FC influx and efflux (ki and ke), from which influx and efflux of FC mass (Fi and Fe) could be calculated. With normal HDL, the uptake and release of FC tracers conformed well to the above-described model; Fi and Fe were approximately equal, suggesting an exchange of FC between cells and HDL. HDL was depleted of phospholipid (PL) by treatment with either phospholipase A2 or heparin-releasable rat hepatic lipase, followed by incubation with bovine serum albumin. PL depletion of HDL had little or no effect on ki, but reduced ke, indicating that PL-deficient HDL is a relatively poor acceptor of cell cholesterol. The reduction in ke resulted in initial Fi greater than Fe and, thus, in net uptake of FC by the cells. This result explained previous results demonstrating net uptake of FC from PL-depleted HDL. In the presence of an inhibitor of acyl coenzyme A:cholesterol acyltransferase, the steady state distribution of FC mass between cells and HDL was accurately predicted by the ratio of rate constants for FC flux. This result provided additional validation for describing FC flux in terms of first-order rate constants and homogeneous cell and HDL FC pools.