Impact of parity and delivery mode on pelvic floor function in young women: a 3D ultrasound evaluation

INTRODUCTION AND HYPOTHESIS

The objectives were to evaluate clinical and anatomical parameters assessed by three-dimensional pelvic floor ultrasound (3D ultrasound) in parous and nulliparous women of childbearing age and to assess underreported symptoms of sexual dysfunction (SD), urinary incontinence (UI) and flatus incontinence (FI).

METHODS

Women without complaints of pelvic floor dysfunction, aged 20-50 years, were eligible for this prospective cross-sectional study. They completed the King's Health Questionnaire, Female Sexual Function Index and St Mark's Incontinence Score adapted for this study. Next, a physical examination and 3D ultrasound were performed. The scores obtained in the questionnaires were compared with the 3D ultrasound data.

RESULTS

In total, 326 women were invited to participate. Of these, 203 women met the inclusion criteria, and their cases were classified as nulliparity (NU, 59), vaginal delivery (VD, 80), forceps delivery (FD, 18) and caesarean section (CS, 48). These groups were homogeneous regarding age (p=0.096), parity (p=0.051) and body mass index (p=0.06). The hiatal dimension (HD; p=0.003) and transverse diameter (TD) (p=0.001) were significantly different among the groups. Compared with the NU and CS groups, the VD and FD groups had an increased HD and TD. The frequencies of underreported symptoms identified by questionnaires were as follows: SD (46.3%), UI (35%) and FI (28%). After VD and FD, women were more likely to present UI (p<0.001), FI (p<0.001) and SD (p=0.002) than the women with NU and those who had undergone a CS. UI was related to a greater HD (p=0.002) and anteroposterior diameter (p=0.022), FI was associated with a thinner left pubovisceral muscle (p=0.013), and SD was related to a greater HD (p=0.026).

CONCLUSIONS

Three-dimensional ultrasound can identify mild morphological changes in young women with apparently normal physical examinations, mainly after VD and FD. In such individuals, these findings are associated with higher incidences of underreported sexual, urinary and anal symptoms.

Plasma and peritoneal fluid concentrations of ceftriaxone after intravenous and intraperitoneal administration in horses

Intraperitoneal (IP) use of antimicrobial agents may lead to therapeutic effects with better clinical results than intravenous (IV) administration. The aim of this study was to compare plasma and peritoneal fluid concentrations of ceftriaxone after IP and IV administration in horses, and to evaluate possible adverse effects. One group of five horses received 25mg/kg ceftriaxone diluted in 1L saline solution by IP catheter once daily for 5 days, while a second group of five horses received 25mg/kg ceftriaxone diluted in 250mL saline solution by IV injection once daily for 5days and 1L saline solution by IP catheter once daily for 5 days. Peritoneal fluid and plasma were collected to determine ceftriaxone concentrations after the first and fifth administration. IP administration of ceftriaxone resulted in concentrations above a minimum inhibitory concentration (MIC) of 1μg/mL for 24h in peritoneal fluid and for 12h in plasma, while IV administration of ceftriaxone resulted in lower peritoneal fluid concentrations, which remained above a MIC of 1μg/mL for 12h in peritoneal fluid and 10h in plasma. No adverse effects were observed. Comparisons of ceftriaxone concentrations, time of occurrence of the maximum (T_max) and minimum (T_min) concentrations, and the mean residence time (MRT), between the two groups showed that IP administration provided greater availability of cephalosporin in peritoneal fluid. The IP use of ceftriaxone (25mg/kg diluted in 1L saline solution once daily) may be useful for the prophylaxis and/or treatment of peritonitis in horses.

Reproducibility in pelvic floor biometric parameters of nulliparous women assessed by translabial three-dimensional ultrasound using Omniview reformatting technique

AIM

To assess the reproducibility of pelvic floor biometric parameters by translabial three-dimensional ultrasound compared with the OmniView® reformatting technique.

MATERIAL AND METHODS

We performed a cross-sectional study involving 47 nulliparous women without symptoms of pelvic floor dysfunction. The hiatal area and right pubovisceral muscle width measurements were performed in the axial plane using both 3D ultrasound in the rendering mode and OmniView® techniques. To determine the occurrence of standardized error between examiners and the two sonographic methods, the paired t-test was used. The intra- and inter-observer reliability and agreement were estimated by concordance correlation coefficient (CCC) and limits of agreement, respectively.

RESULTS

We did not observe significant statistical differences among both measurements performed by the first examiner, both examiners and both methods in the assessment of the hiatal area; however, the measurements of the right pubovisceral muscle were significantly lower using OmniView®. The intra-observer reliability was good in the evaluation of all pelvic floor parameters; however, the inter-observer reliability was good only to the 3D rendering mode (CCC=0.87). The intra-observer agreement was good in the assessment of all pelvic floor parameters; however, the inter-observer agreement was found to be good only when 3DUS in the rendering mode was used (<+/-15%).

CONCLUSION

Both 3D ultrasound in the rendering mode and OmniView® reformatting techniques were concordant in the assessment of pelvic floor parameters; however, the 3D ultrasound rendering in the mode demonstrated better inter-observer reliability and agreement.

Effectiveness of adding voluntary pelvic floor muscle contraction to a Pilates exercise program: an assessor-masked randomized controlled trial

INTRODUCTION AND HYPOTHESIS

The purpose of this study was to evaluate the effectiveness of adding voluntary pelvic floor muscle contraction (PFMC) to a Pilates exercise program in sedentary nulliparous women.

METHODS

Fifty-seven healthy nulliparous and physically inactive women were randomized to a Pilates exercise program (PEP) with or without PFMC. Forty-eight women concluded this study (24 participants for each group). Each woman was evaluated before and after the PEP, by a physiotherapist and an urogynecologist (UG). Neither of the professionals was revealed to them. This physiotherapist measured their pelvic floor muscle strength by using both a perineometer (Peritron) and vaginal palpation (Oxford Scale). The UG, who performed 3D perineal ultrasound examinations, collected their data and evaluated the results for pubovisceral muscle thickness and the levator hiatus area (LA). Both professionals were blinded to the group allocation. The protocol for both groups consisted of 24 bi-weekly 1-h individual sessions of Pilates exercises, developed by another physiotherapist who specializes in PFM rehabilitation and the Pilates technique.

RESULTS

The PEP+ PFMC group showed significantly greater strength improvements than the PEP group when comparing the Oxford scale, vaginal pressure and pubovisceral muscle thickness during contraction measurements at baseline and post-treatment.

CONCLUSIONS

Our findings suggest that adding a voluntary PFMC to a Pilates exercise program is more effective than Pilates alone in improving PFM strength in sedentary nulliparous women.

Digital venography in ruminants--a review

Digital venography is a contrast angiography technique used to study digital vascularity. The technique is simple to be carried out and can be performed under field conditions using a standard radiographic unit. The venogram examination is used to complement conventional radiographic examinations in animals affected by foot diseases. Discrepancy in the contrast vascular pattern may be observed before the clinical signs of the foot disease. Digital venography studies in ruminants are in smaller number than those in horses. The herein presented review discusses digital venography techniques used in ruminants as well as the differences and similarities between ruminants (cattle, sheep and goat) and horses.

Surface Morphology and Structural Modification Induced by Femtosecond Pulses in Hydrogenated Amorphous Silicon Films

This work investigates the modification, resulting from fs-laser irradiation (150 fs, 775 nm and 1 kHz), on the structure and surface morphology of hydrogenated amorphous silicon (a-Si:H) thin films. The sample morphology was studied by performing a statistical analyzes of atomic force microscopy images, using a specially developed software that identifies and characterizes the domains (spikes) produced by the laser irradiation. For a fluence of 3.1 MJ/m2, we observed formation of spikes with smaller average height distribution, centered at around 15 nm, while for fluencies higher than 3.7 MJ/m2 aggregation of the produced spikes dominates the sample morphology. On the other hand, Raman spectroscopy revealed that a higher crystalline fraction (73%) is obtained for higher fluences (> 3.1 MJ/m2), which is accompanied by a decrease in the size of the produced crystals. Therefore, such results indicate that there is a trade-off between the spike distribution, crystallization fraction and size of the nanocrystals attained by laser irradiation, which has to be taken into account when using such approach for the development of devices.

Plasma anti-mullerian hormone: an endocrine marker for in vitro embryo production from Bos taurus and Bos indicus donors

The aim of this study was to evaluate the association between plasma anti-mullerian hormone (AMH) concentration and in vitro embryo production (IVP) from Bos taurus (Holstein) and Bos indicus (Nelore) donors. A total of 59 Holstein (15 prepubertal heifers aged 8-10 mo, 15 cyclic heifers aged 12-14 mo, 14 lactating cows, and 15 nonlactating cows) and 34 Nelore (12 prepubertal heifers aged 10-11 mo, 10 prepubertal heifers aged 21-23 mo, and 12 cyclic heifers aged 24-26 mo) females were enrolled. All females underwent an ovum pick-up (OPU), without previous synchronization of the follicular wave, and IVP procedure. Immediately before the OPU procedure, blood samples were collected for subsequent AMH determination. A positive correlation was observed between the plasma AMH and number of in vitro embryos produced from Holstein (r = 0.36, P < 0.001) and Nelore (r = 0.50, P = 0.003) donors. For additional analyses, donors within each genotype were classified into 1 of 2 AMH categories (low or high) according to the average AMH concentration for each genotype. The results revealed that females classified as having high AMH presented a greater number of visible aspirated follicles (Holstein: 20.9 ± 1.5 vs 13.6 ± 0.9, P < 0.0001; Nelore: 54.3 ± 6.1 vs 18.6 ± 2.1, P < 0.0001) and a greater number of recovered cumulus-oocyte complexes (Holstein: 17.3 ± 1.5 vs 9.0 ± 0.9, P < 0.0001; Nelore: 45.3 ± 6.4 vs 13.4 ± 1.7, P < 0.0001). However, there was no difference in the blastocyst production rate (Holstein: 20.6% ± 4.0% vs 19.8% ± 4.2%, P = 0.60; Nelore: 33.7% ± 6.5% vs 27.4% ± 5.5%, P = 0.41, high and low AMH, respectively). Moreover, donors classified as having high AMH yielded a greater number of embryos produced per OPU (Holstein: 3.0 ± 0.7; Nelore: 7.0 ± 1.7) compared with those classified as having low AMH (Holstein: 1.2 ± 0.3, P = 0.04; Nelore: 2.2 ± 0.5, P = 0.007). In conclusion, although the plasma AMH concentration did not alter the ability of the cumulus-oocyte complex to reach the blastocyst stage, the AMH concentration in plasma can be an accurate endocrine marker for the in vitro embryo yield from either B. taurus (Holstein) or B. indicus (Nelore) donors. Therefore, AMH is a promising tool to enhance the overall efficiency of OPU-IVP programs in the field as a selective criterion for high embryo producing donors.

Social diagnosis of chronic kidney disease patients in preparation for living donor renal transplantation

BACKGROUND

The relationship between socioeconomic status and clinical outcome in health and disease is complex and multifactorial. An association between low socioeconomic status and shorter patient survival in renal replacement therapy, dialysis, and transplantation, has been reported, implicating individual and environmental factors. We sought to analyze the socioeconomic and demographic characteristics of chronic kidney disease (CKD) patients in preparation for living kidney transplantation.

METHODS

We evaluated 60 patients with CKD-V, on hemodialysis or peritoneal dialysis and who were being prepared in our public service between July 2008 and January 2010. Socioeconomic data were collected from the records.

RESULTS

The mean age was 44.8 ± 13.3 years and 51% were male. Sixty-three percent were married, most of them with children, with a family size of 3.5 ± 1.45 members. They were taken a mean of 5.8 ± 2.8 drugs; only half of them were dispensed by public health insurance. Almost all--93%--did not work regularly, and the majority reported some limitation in daily activities. The mean monthly income was US $1,535.70 and 76.2% reported a monthly income ≤ US $1,810.60. The mean of school years was 7.91 ± 4.19.

CONCLUSION

Low-income patients are gaining access to preparing for renal transplantation; we believe that is inherent to the universal structure of Brazil's public health system. Besides the low income, this population showed a considerable educational level, suggesting this characteristic made the patient more active to search the living transplant as an alternative for their CKD treatment. Knowledge about social status is essential for design strategies in minimizing its potential undesirable effects after transplantation.

Oxaliplatin-related thrombocytopenia

Oxaliplatin is a third generation platinum compound that inhibits DNA synthesis, mainly through intrastrandal cross-links in DNA. Most of the experience with the clinical use of this drug is derived from colorectal cancer but it is also used in other tumor types such as ovary, breast, liver and non-Hodgkin's lymphoma. Thrombocytopenia is a frequent toxicity seen during oxaliplatin treatment, occurring at any grade in up to 70% of patients and leading to delays or even discontinuation of the chemotherapy. Although myelossupression is recognized as the main cause of oxaliplatin-related thrombocytopenia, new mechanisms for this side-effect have emerged, including splenic sequestration of platelets related to oxaliplatin-induced liver damage and immune thrombocytopenia. These new pathophysiology pathways have different clinical presentations and evolution and may need specific therapeutic maneuvers. This article attempts to review this topic and provides useful clinical information for the management of oxaliplatin-related thrombocytopenia.

Pharmacokinetics of tetracycline in plasma, synovial fluid and milk using single intravenous and single intravenous regional doses in dairy cattle with papillomatous digital dermatitis

The purpose of this study was to compare the pharmacokinetics of tetracycline in plasma, synovial fluid, and milk following either a single systemic intravenous (i.v.) injection or a single i.v. regional antibiosis (IVRA) administration of tetracycline hydrochloride to dairy cattle with papillomatous digital dermatitis (PDD). To this end, plasma and synovial fluid tetracycline concentrations were compared with the minimal inhibitory concentration (MIC) values of the major bacteria, which are known to cause digital diseases and thus assess its efficacy in PDD. Residual tetracycline concentrations in milk from cows treated by both methods were also determined. Twelve Holstein cows with various stages of PDD were randomly assigned to two groups of six animals. Group 1 received a single systemic i.v. injection of 10 mg/kg of tetracycline hydrochloride. Group 2 received 1000 mg of tetracycline hydrochloride by IVRA of the affected limb. Blood, synovial fluid and milk samples were taken prior to tetracycline administration (time 0 control), and then at 22, 45 and 82 min, and 2, 3, 4, 6, 8, 12, 24, 48, 72, 96, and 120 h following drug administration. Tetracycline concentrations were determined by high-performance liquid chromatography. Mean tetracycline plasma and milk concentrations in Group 1 were higher than Group 2. The opposite was observed for synovial fluid concentrations. Group 2 synovial fluid concentrations were higher than the MIC value over 24 h for the bacteria most frequently responsible for claw disease. Compared with i.v. administration, IVRA administration of tetracycline produced very high synovial fluid and low plasma and milk concentrations.

A retrospective comparison of cyclophosphamide plus antithymocyte globulin with cyclophosphamide plus busulfan as the conditioning regimen for severe aplastic anemia

Allogeneic hematopoietic stem cell transplantation (AHSCT) is the treatment of choice for young patients with severe aplastic anemia (SAA). The association of antithymocyte globulin (ATG) and cyclophosphamide (CY) is the most frequently used conditioning regimen for this disease. We performed this retrospective study in order to compare the outcomes of HLA-matched sibling donor AHSCT in 41 patients with SAA receiving cyclophosphamide plus ATG (ATG-CY, N = 17) or cyclophosphamide plus busulfan (BU-CY, N = 24). The substitution of BU for ATG was motivated by the high cost of ATG. There were no differences in the clinical features between the two groups, including age, gender, cytomegalovirus status, ABO match, interval between diagnosis and transplant, and number of total nucleated cells infused. No differences were observed in the time to neutrophil and platelet engraftment, or in the risk of veno-occlusive disease and hemorrhage. However, there was a higher risk of mucositis in the BU-CY group (71 vs 24%, P = 0.004). There were no differences in the incidence of neutrophil and platelet engraftment, acute and chronic graft-versus-host disease, and transplant-related mortality. There was a higher incidence of late rejection in the ATG-CY group (41 vs 4%, P = 0.009). Although the ATG-CY group had a longer follow-up (101 months) than the BU-CY group (67 months, P = 0.04), overall survival was similar between the groups (69 vs 58%, respectively, P = 0.32). We conclude that the association BU-CY is a feasible option to the conventional ATG-CY regimen in this population.

Effect of fixed-time embryo transfer on reproductive efficiency in high-producing repeat-breeder Holstein cows

The aim of the present study was to compare a synchronization of time of ovulation protocol for fixed-timed embryo transfer (FTET) with the usual administration of a single dose of prostaglandin associated with detection of estrus. Also, the effect of the presence of CL at the beginning of FTET protocol was evaluated. Lactating Holstein cows (n=651) with three previous artificial inseminations were classified according to presence or absence of a corpus luteum (CL). Cows with a CL were randomly assigned to two additional treatments and submitted to embryo transfer after detection of estrus (PGF-Estrus) or FTET (FTET-CL). Cows without CL were allocated to the FTET-NoCL treatment. On a random day of the estrous cycle (Day 0), cows in the PGF-Estrus treatment (n=229) were treated with 150 microg d-cloprostenol (PGF) i.m. followed by detection of estrus from Day 1 through Day 5 after PGF. Embryos were transferred 6-8 days after estrus detection. Cows in the FTET-CL (n=208; presence of CL) and FTET-NoCL (n=214; absence of CL) treatments received a norgestomet ear implant plus 2mg estradiol benzoate (EB) and 50mg progesterone i.m. on Day 0. On Day 8, the implant was removed and 400 IUeCG, 150 microg d-cloprostenol and 1mg estradiol cypionate i.m. were administered. No detection of estrus was performed and Day 10 was arbitrarily considered as the estrus day. Ultrasonographic exams were performed in all recipients and only cows with a single CL> or =15 mm or multiple CL received a fresh or frozen-thawed embryo on Day 17. Pregnancy was diagnosed by ultrasonography at 30 and 60 days of pregnancy. When FTET and PGF-Estrus were compared, the proportion of cows receiving an embryo (recipients transferred-to-treated rate) was greater in the FTET-CL (75.0% (156/208) than in PGF-Estrus (34.5%, 79/229; P<0.0001) treatment. Pregnancy rate (60 days) was also greater in FTET-CL (29.3%, 61/208) when compared to PGF-Estrus (16.2%, 37/229; P=0.001). However, no differences were found in pregnancy loss [PGF-Estrus=11.9% (5/42), FTET-CL=9.0% (6/67); P=0.62] and circulating progesterone concentration at embryo transfer [PGF-Estrus=4.02+/-0.52 ng/mL (n=25), FTET-CL=3.33+/-0.32 ng/mL (n=27); P=0.25] among these treatments. The presence of CL at the beginning of FTET protocol resulted greater transferred-to-treated rate [FTET-CL=75.0% (156/208) vs. FTET-NoCL=61.2% (131/214); P=0.003], but showed no effect on pregnancy rate at 60 days [FTET-CL=29.3% (61/208) vs. FTET-NoCL=22.9% (49/214); P=0.13], pregnancy loss [FTET-CL=9.0% (6/67) vs. FTET-NoCL=2.0% (1/50); P=0.15] and circulating progesterone concentration at ET [FTET-CL=3.33+/-0.32 ng/mL (n=27) compared to FTET-NoCL=3.44+/-0.40 ng/mL (n=2 9); P=0.82]. In conclusion, the protocol for synchronization of time of ovulation using norgestomet ear implant, EB and eCG increased recipients transferred-to-treated and pregnancy rates in high-producing repeat-breeder Holstein cows. Also, recipients without CL at the beginning of the time of ovulation synchronization treatment resulted in similar pregnancy rate as recipients with CL submitted to FTET protocol. Thus, the suggested protocol allowed the performance of FTET, without the need for detection of estrus, simplifying the reproductive management and increasing the reproductive efficiency in repeat-breeder Holstein recipients.

Double cord blood transplantation in patients with high risk bone marrow failure syndromes

Patients with bone marrow failure syndromes (BMFS) who reject a first allogeneic transplant or fail immunosuppressive therapy (IST) have an especially grim prognosis. We report 14 patients (eight adults, six children) transplanted with double cord blood transplantation (dUCBT) for BMFS. Neutrophil recovery was observed in eight patients, with full donor chimerism of one unit, and acute GVHD in 10. With a median follow-up of 23 months, the estimated 2 years overall survival was 80 +/- 17% and 33 +/- 16% for patients with acquired and inherited BMFS, respectively. Transplantation of two partially HLA-matched UCB thus enables salvage treatment of high-risk patients with BMFS.

The use of chitosan modified with glutaraldehyde and glyoxal as chromatographic support for the separation of flavonoids from Aleurites moluccana leaves

This paper describes the preparation of chitosan modified with dialdehydes, glutaraldehyde (CH-Glu) and glyoxal (CH-Gly) and its application in the isolation of the flavonoids swertisin and 2"-O-rhamnosylswertisin from A. mollucana. The additional non-polar alkyl groups increase the hydrophobicity of the sorbent. The results show that the separation was mediated by hydrophobic interaction (CH-Glu), as well as hydrogen bonding, between phenolic OH or rhamnosil residues from the flavonoids, and the free amine groups (CH-Gly).

Factors potentially affecting fertility of lactating dairy cow recipients

Objectives of this study were to evaluate factors that could affect pregnancy rate after embryo transfer (ET) in lactating dairy cow recipients. The trial was conducted at a dairy farm located in Descalvado, SP, Brazil from October 2003 to September 2004. From 1037 cows with CL that were treated with an injection of PGF2alpha, 43.3% were detected in heat; 263 were previously assigned at day of PGF2alpha injection for AI and 186 for ET. Ovulation rate was 85.7% (385/449). Pregnancy rate for cows with CL for AI and embryo transfer recipients were 36.5% (84/230) and 58.7% (91/155) at day 25 and 33.0% (76/230) and 45.8% (71/155) at day 46, respectively. Embryonic loss were 9.5% (8/84) for the AI group and 21.9% (20/91) for the ET group. Average milk production was 31.4 L/day/cow. Average daily milk production from 7 days before PGF2alpha injection to 7 days after ET tended (P < 0.10) to influence pregnancy rate on days 25 and 46. Average daily milk production from the day of embryo transfer to 7 days after influenced embryonic loss (P < 0.05). Cows with higher milk production had lower probability of pregnancy and higher probability of embryonic loss. Cows with higher days in milk had higher probability of pregnancy. Cows with higher rectal body temperature had lower probability of pregnancy and higher probability of embryonic loss. The influence of high milk yield and body temperature on fertility in lactating dairy cow recipients suggests that these effects can occur also after embryo reaches the blastocyst stage.

Importance of combined-modality therapy for primary bone lymphoma

Primary bone lymphoma (PBL) is a rare entity and comprises about 5% of all extranodal non-Hodgkin's lymphomas (NHL) and 7% of all primary bone tumors. To date there is no consensus about the optimal treatment for PBL. We retrospectively reviewed all cases of PBL treated at Hospital São Paulo, Brazil, over a 10-year-period (January 1992-January 2002). Medical records of 7 patients with PBL were reviewed and information on age at diagnosis, sex, NHL clinical staging (CS), treatment and response to treatment were retrieved. Five patients (72%) received combined-modality therapy (CMT) and all of them are in complete remission (CR) with a median follow up of 19 months (ranging from 12 to 144 months). We conclude that PBL is a potentially curable malignancy and treatment should be undertaken in a multiprofessional approach, in order to provide the best support which probably has to include chemotherapy, radiotherapy and, for patients with IPI higher than 2, consolidation with stem-cell transplantation.

Isolation of flavonoids from Aleurites moluccana using chitosan modified with benzaldehyde (CH-Bz) as chromatographic support

This paper describes the preparation, characterization and use of a derivative of chitosan as a chromatographic sorbent. Chitosan modified with benzenic ring (CH-Bz) was used to separate two flavonoids, swertisin and 2"-O-rhamnosylswertisin, from ethyl acetate fraction of Aleurites moluccana. The results showed that CH-Bz can be used as a sorbent for the separation of flavonoid compounds. The studies showed that CH-Bz in column chromatography produces goods results, separation of the flavonoid compounds.

Refractory chronic GVHD emerging after splenectomy in a marrow transplant recipient with accelerated phase CML

We report a 39-year-old female patient who underwent HLA-identical sibling allogeneic BMT for CML in accelerated phase. Severe pancytopenia refractory to G-CSF associated with progressive splenomegaly and RBC/platelet transfusion dependency were present from day +60 after BMT. MRD assessed by FISH and RT-PCR multiplex for BCR-ABL rearrangement was negative, and complete chimerism was documented by VNTR on days +100, +180, +360 and 2 years after BMT. Splenectomy was performed on day +225 and pancytopenia resolved but chronic extensive graft-versus-host disease developed, with hepatic cholestasis, diffuse scleroderma and sicca-like syndrome. She was sequentially and progressively treated with different immunosuppressive therapy combinations with no clear benefit. On day +940, she presented with infection over the previously present ulcers on both limbs, which culminated in septic shock and death on day +1041. We conclude that, although splenectomy may reverse poor graft function after allogeneic BMT, hyposplenism may trigger or worsen chronic extensive GVHD leading to increased morbidity and mortality.

Acute myeloid leukemia in elderly patients: experience of a single center

Acute myeloid leukemia (AML) is a disease predominantly of older adults. Treatment of AML in the elderly is complicated not only by comorbidities but also by the high prevalence of poor prognosis markers. Thirty-one consecutive unselected patients with AML older than 60 years (representing 33% of all AML cases diagnosed at our institution during the same period) were followed over a period of 5 years (1997-2002). A high incidence of AML with multilineage dysplasia (45%) and no favorable cytogenetic abnormalities but 62% intermediate and 38% unfavorable karyotypes were found. Sixteen patients (52%) were selected for induction of intensive cytotoxic treatment and complete remission was achieved only by some of these intensively treated patients (7 of 16). Of these, 3 remained alive without disease (median: 11 months), 1 patient died shortly after complete remission, and 3 patients relapsed and died from refractory disease. Only 1 patient that was refractory to intensive cytotoxic treatment remained alive with disease under supportive care. Fifteen patients (48%) were managed with palliative/supportive care: 7 received palliative treatment and supportive care, 8 received supportive care only, and 4 patients remained alive with disease under supportive care (median: 9 months). Mortality rate was 74% and overall survival at two years was 12%. To the best of our knowledge, there is no previous report regarding elderly patients with AML in Brazilian subsets. The present data are similar to previously reported studies showing that elderly AML patients are not only older but also biologically distinct from younger AML patients, particularly in terms of the high incidence of poor prognostic karyotypes and resistance to therapy.

Ultrastructural study of expression of adhesion molecules between blood monocytes and alveolar macrophages from patients with pulmonary sarcoidosis

Pulmonary sarcoidosis is a chronic inflammatory disorder characterized by the presence of activated T cells and alveolar macrophages at sites of inflammation. These cells are recovered from bronchoalveolar lavage (BAL) from sarcoid patients in order to evaluate the expression of various markers on cell surfaces that should determine the diagnosis in sarcoidosis. In this work we compared the expression of VLA-4, VLA-5, Mac-1, ICAM-1 and VCAM- 1 adhesion molecules, at ultrastructural level, between blood monocytes and alveolar macrophages obtained from BAL, from patients with pulmonary sarcoidosis. Cells obtained from blood and BAL were fixed, embedded in LRWhite and then ultrathin sections were incubated with monoclonal antibodies against VLA-4, VLA-5, Mac-1, ICAM-1 and VCAM-1. The results showed a more evident labelling of all adhesion molecules on alveolar macrophages when compared to blood monocytes. The labelling was seen at cell surface, at cytoplasm and small vacuoles. The differences on adhesion molecule distributions from blood monocytes to alveolar macrophages suggest that changes in the expression of these molecules occur during pulmonary inflammatory response. Lymphocytes from BAL or blood had a weak label for these molecules.

Cross-linking chitosan-Fe(III), an oral phosphate binder: studies in vitro and in vivo

The objective was to evaluate the in vitro and in vivo phosphate binding properties of cross-linked chitosan iron (III) (CH-Fe(III)-CL), a potential oral phosphate binder for treating hyperphosphatemia. At equilibrium, the in vitro phosphate binding of CH-Fe(III)-CL was 23.6 mg g(-1) for simulated gastrointestinal conditions. In hyperphosphatemic rats, CH-Fe(III)-CL was similar to iron sulfate in reducing serum phosphate by about 35%.

[The city and the death: yellow fever and its impact on funeral customs in Rio de Janeiro (1849-50)]

During the summer of 1849-50, a yellow fever epidemic hit the city of Rio de Janeeiro. In analyzing the epidemic's impact on local funeral customs, the article asked to what extent the subsequent high mortality rate was a catalyst that changed people's attitudes towards death and the deceased. The central hypothesis is that the epidemic was the final argument physicians needed to convince the imperial government and the population to implement these doctors' project, one which would medicalize death and standardize funeral customs.

Identification of M.leprae in conjunctiva of leprosy patients using the superior tarsal conjunctiva scrape technique

The technique of superior tarsal conjunctiva scrape was used for identifying M.leprae in the conjunctiva in 56 leprosy patients (all of them multibacillary, some untreated and others treated with multidrug therapy). The technique of tarsal conjunctiva scrape was shown to be more suitable than conjunctival biopsy for identifying lepra bacilli. This technique is also easier to perform and has shown a statistical relation between bacilloscopical index of skin (BIsk) and bacilloscopical index of tarsal conjunctiva (BIconj) values. Thus, if the bacilli can be identified at tarsal conjunctiva we can assume greater systemic bacillary load in the patients.

Conjunctival biopsy in patients with leprosy

The authors examined the eyes of 120 leprosy patients comprising of 30 cases each of tuberculoid, indeterminate, borderline and lepromatous leprosy. The investigation included biopsy of the bulbar conjunctiva on the upper temporal quadrant of the right eye. The study patients included both who were untreated, those that were being treated and those who were in observation after the end of treatment. The aim of the study was to identify the presence of M. leprae in the conjunctiva. Four such cases were found: one borderline patient with no treatment and three lepromatous patients who were being treated with MDT.

Bilateral iridocyclitis caused by Mycobacterium leprae diagnosed through paracentesis

The authors conducted an anterior chamber paracentesis in a patient with lepromatous leprosy showing bilateral iridocyclitis. The paracentesis was performed in the outpatients department. The aqueous humor was studied by Ziehl-Nielsen staining method and the result was the isolation of the M. leprae in the anterior chamber. This study shows that M. leprae can promote uveitis in leprosy patients. Therefore, it should be looked for in patients having this type of disease.

Improved maintenance of remission in ulcerative colitis by balsalazide 4 g/day compared with 2 g/day

The efficacy of two doses of balsalazide for the maintenance of remission in patients with ulcerative colitis was compared in a double-blind multicentre trial. Sixty-five patients received a 2 g daily dose, and 68 a 4 g dose. The patient groups were similar at entry for sex, age, and disease distribution. Clinical assessment was carried out at 3-monthly intervals, with sigmoidoscopy, rectal biopsy, and blood tests on entry and at 26 and 52 weeks. Clinical relapse over twelve months was significantly less common on the 4 g dose (36%), than on the 2 g dose (55%), P less than 0.01. There were eight withdrawals on 2 g daily and 13 on 4 g daily, six and nine respectively being mainly due to gastrointestinal intolerance. It is concluded that balsalazide is a well-tolerated drug, and is effective for the maintenance of remission in patients with ulcerative colitis, the optimal dose being greater than 2 g daily.

Patent foramina ovale in elderly stroke patients

Fifty elderly patients who had suffered cerebrovascular incidents from no obvious cause and 33 age-matched controls were investigated for the presence of a patent foramen ovale by contrast 2-dimensional echocardiography at rest and after the Valsalva manoeuvre. Right-to-left shunting was found in only one patient and in none of the controls. This finding is in contradistinction to young adult stroke patients in whom the prevalence of a haemodynamically significant patent foramina ovale is high. Paradoxical embolism is an uncommon cause of stroke in the elderly.

Financial analysis of pseudorabies control and eradication in swine

Computerized decision-tree analysis and simulation modeling were used to evaluate control and eradication strategies for pseudorabies virus (PRV) in swine. Three alternative actions were considered for a hypothetical 100-sow, farrow-to-finish operation: (1) depopulation-repopulation, (2) test-and-removal of seropositives (T&R), and (3) vaccination (of the entire herd or of sows only). The expected monetary values for the vaccination and T&R alternatives were similar, which was consistent with the long-standing controversy over the best strategy for dealing with PRV. When the prevalence rate of PRV was less than or equal to 57%, T&R was found to be optimal; otherwise, vaccination of sows only was recommended. Sensitivity analysis was performed to determine how modifications in some of the original assumptions affected the expected monetary values of each strategy. When higher gross margins for the producer were assumed, T&R was preferred at all prevalence rates. Vaccination was preferred when lower gross margins, lower vaccination costs, or better protective effect of PRV vaccines on reproductive performance were assumed. The use of gene-deleted vaccines in conjunction with the T&R strategy was also evaluated. When this option was available, T&R was favored at any prevalence rate (T&R alone when the prevalence was less than or equal to 20%, or combined with gene-deleted vaccination at prevalences greater than 20%). Depopulation-repopulation was not the best option under any circumstance. Once formulated, a decision-tree analysis can be adapted to the prevailing economic or epidemiologic conditions; hence, it is a useful tool in the PRV decision-making process.

Familial visceral myopathy: a family with at least six involved members

A family with at least six members affected by hollow organ visceral myopathy is described. Patients in the first or second decades of life developed symptoms which included weight loss, nausea and vomiting, abdominal pain and distension, constipation and diarrhoea, and urinary symptoms. The radiological features of the disease consisted of oesophageal aperistalsis, megaduodenum, and variable dilatation of the small and large bowel. Four patients had urinary tract involvement with dilatation of the ureters and/or incomplete bladder emptying. Two patients were severely affected and needed home parenteral nutrition and surgical treatment; others were symptomatic but remained well. The characteristic pathological abnormality was vacuolar degeneration predominantly affecting the longitudinal muscle. The disease in this family appears to be transmitted by autosomal dominant mode of inheritance.

The effects of octreotide, soy polysaccharide, codeine and loperamide on nutrient, fluid and electrolyte absorption in the short-bowel syndrome

Four agents, which could delay intestinal transit, were tested in six short-bowel patients (jejunal length 30-120 cm) on long-term nutritional/electrolyte replacement therapy. Intestinal transit time of a liquid test meal and nutrient, water and sodium absorption were measured during a control study and with each test agent on separate days. Soy polysaccharide tended to increase transit time, but decreased the absorption of water, sodium and nutrients. Codeine phosphate and loperamide caused inconsistent and clinically unimportant changes. Octreotide, a long-acting analogue of somatostatin, delayed transit and increased water, sodium and calorie absorption from the meal. Octreotide appears to have the potential to reduce the need for electrolyte and nutritional supplements in patients with the short-bowel syndrome.

Energy absorption as a measure of intestinal failure in the short bowel syndrome

Energy absorption from a liquid test meal, intestinal transit rate and water and sodium output over a six hour period were measured in five patients with an ileostomy and 12 patients with the short bowel syndrome, five of whom were on longterm parenteral nutrition. The proportion of total energy absorbed was greatest in the ileostomists (median 87%, range 82-92%), less in short bowel patients not on parenteral nutrition (median 67%, range 59-78%, p less than 0.01) and least in the short bowel group who needed it (median 27%, range 2-63%, p less than 0.01). Transit rate was more rapid in the short bowel patients compared with the ileostomists. A close correlation was observed between percentage energy absorption and the dry weight of the stools/stoma effluent collected during the six hour test period (r = -0.99, p less than 0.001). This simple non-invasive test quantitates the degree of intestinal failure and may be of practical help in management.

Balsalazide in the maintenance treatment of patients with ulcerative colitis, a double-blind comparison with sulphasalazine

Balsalazide (BSZ) is a pro-drug which releases 5-aminosalicylic acid (5ASA) and 4-aminobenzoyl-beta-alanine (an inert carrier) in the colon of various species including man. BSZ was compared with sulphasalazine (SASP) (both 1 g b.d. orally) in the maintenance of remission in patients with ulcerative colitis (UC). Seventy-nine patients (53 male, 26 female), mean age 49 years (range 19-79 years), with UC were randomly allocated to either treatment (41 BSZ, 38 SASP) for 6 months. The groups were similar in respect of age, sex, duration and extent of disease. Seven patients defaulted (3 BSZ, 4 SASP) leaving 38 on BSZ and 34 on SASP. Two male patients, both receiving SASP, were withdrawn because of severe side-effects. One of these patients, with an exfoliative rash, was maintained satisfactorily on open BSZ. Remission rates at 6 months (51% BSZ, 63% SASP) were not significantly different (life-table analysis P less than 0.1). Twelve patients (15%) reported troublesome side-effects (2 BSZ 5%, 10 SASP 26%, P = 0.017 Fisher Exact Test). Mean haemoglobin concentrations, similar on entry, increased after 6 months with BSZ (0.2 g/dl) but decreased with SASP (0.5 g/dl) (P less than 0.0002). BSZ was not significantly different from SASP in maintaining remission in patients with UC but had fewer side-effects.

Prednisolone absorption in inflammatory bowel disease: correlation with anatomical site and extent

Prednisolone absorption was studied in 13 normal subjects, eight patients with ulcerative colitis and 21 patients with Crohn's disease, by measuring plasma levels after a single oral dose. Absorption of the drug was delayed in all patient groups. The peak plasma level of the drug was lower in patients with extensive small bowel Crohn's disease. Patients in this category may need higher doses of oral prednisolone than other patients with inflammatory bowel disease.