Distal spleno-renal shunt versus endoscopic sclerotherapy in the prevention of variceal rebleeding. A meta-analysis of 4 randomized clinical trials

Meta-analysis was used to evaluate 4 clinical trials comparing distal spleno-renal shunt (DSRS) with endoscopic sclerotherapy (EVS) in the prevention of variceal rebleeding: the interval between bleeding and therapy ranges from 100 days. A questionnaire was sent to each author of the published trials concerning methods, definitions and results of the trials in order to obtain more detailed and up-to-date information. The selected end-points for the meta-analysis were: rebleeding, mortality and chronic encephalopathy. Analysis of the results in the questionnaires was made using the method proposed by Collins. The pooled relative risk (i.e. the combined Odds ratio of each trial as an estimate of overall efficacy) of rebleeding was statistically reduced by DSRS (0.16; 95% confidence interval 0.10-0.27). Despite this, the overall risk of death following DSRS was only marginally decreased (0.78; 95% confidence interval 0.47-1.29); the lack of homogeneity in the results does not permit any significant conclusions on this end-point. However, in non-alcoholic patients, the decrease in risk of death was greater, and this without heterogeneity, following DSRS than EVS (0.59; 95% confidence interval 0.23-1.50). The overall risk of chronic encephalopathy was slightly increased after DSRS (1.86; 95% confidence interval 0.90-3.86). In conclusion, DSRS significantly reduced the risk of rebleeding compared to EVS without increasing the risk of chronic hepatic encephalopathy. However, DSRS did not significantly affect the overall death risk. Only in non-alcoholic disease did it seem to show an advantage over EVS

Vertical transmission of HIV-1: Maternal immune status and obstetric factors

Objective: To estimate the effect of maternal factors and events around the time of delivery on HIV-1 vertical transmission risk. Design: Prospective study. Setting: Twenty-two obstetric and paediatric clinics in seven European countries. Patients or other participants: Mothers identified as HIV-infected before or at delivery and their children. Main outcome measure: Paediatric HIV infection. Results: By November 1995, 1846 mothers with 1945 children had been enrolled. The vertical transmission rate was 16.4% (95% confidence interval, 14.5-18.3). Parity, maternal age, race, mode of HIV acquisition, injecting drug use and sex of infant were not statistically significantly associated with risk of transmission, Children delivered vaginally were more likely to be infected than those delivered by Caesarean section. However, in vaginal deliveries the procedures used, duration of ruptured membranes or length of second-stage labour were not related to transmission. Transmission increased almost linearly with decreasing CD4 cell count, but there was no such trend for CD8 cell count. Women with CD4 cell counts below 200 x 10(6)/l were significantly more likely to deliver early (chi(2) for trend, 14.02; P < 0.001). Very premature infants were at increased risk of infection, but after about 35 weeks gestation the transmission rate remained stable, with no increase in late pregnancy. This trend was confirmed after allowing for maternal CD4 cell count. Conclusions: The rate of vertical transmission increases linearly with decreasing maternal CD4 cell count. Women with fewer than 200 x 10(6) CD4 cells/l have an increased risk of premature delivery, which would affect timing of interventions. The stable transmission rate after 35 weeks gestation suggests little acquisition of infection during late pregnancy

Cesarean-section and Risk of Vertical Transmission of Hiv-1 Infection

Indirect evidence suggests that a significant proportion of vertical transmission of HIV infection occurs late in pregnancy or during delivery. Caesarean section, therefore, may protect the fetus from infection. We looked at 1254 HIV-infected mothers and their children and the effects of different modes of delivery on transmission risk. We also included a detailed assessment of confounding factors associated with transmission risk. Women who had caesarean sections were more advanced in their disease progression which may cause the protective effect of caesarean section to be underestimated. When this and other potential confounding factors were taken into account, caesarean section was estimated to halve the rate of transmission. This finding is important in the design of studies to evaluate treatments aimed at reducing mother-to-child transmission

Perinatal Findings In Children Born To Hiv-infected Mothers

Objective To explore in children born to HIV-infected women, the association between a child's HIV infection status and birthweight, gestational age, congenital abnormalities and other perinatal findings. Design A prospective study of children born to women known to be HIV-infected at or before the time of delivery enrolled in the European Collaborative Study. Setting Nineteen European centres. Subjects A cohort of 853 children with known HIV infection status. Results There was no evidence for an HIV dysmorphic syndrome, and the frequency of congenital abnormalities was similar in infected and uninfected children with no consistent pattern of defects. Injecting drug use during pregnancy had the most marked effect on birthweight and gestational age. Multivariate analysis demonstrated a weak association between birthweight and the child's HIV infection status, but this could partly be explained by the confounding effect of maternal immunological HIV status. HIV infection in the infant was not associated with gestational age, and the mean and distribution of gestational age were similar for infected and noninfected children. Conclusions The finding that HIV-infected and noninfected children are of similar birthweight, the absence of a dysmorphic syndrome and no evidence of associated congenital abnormalities suggest that a substantial proportion of infection occurs late in pregnancy or at the time of delivery