Lower uterine segment thickness assessed by transvaginal ultrasound before labor induction: reproducibility analysis and relationship with delivery outcome

OBJECTIVES

To evaluate the reproducibility of lower uterine segment (LUS) thickness measurement before induction of labor (IOL), and to assess the relationship between LUS thickness and IOL outcomes.

METHODS

This was a prospective cohort study of pregnant women undergoing IOL at term, conducted in a single tertiary hospital between July 2014 and February 2017. Women with a singleton pregnancy at ≥ 37 weeks' gestation, with a live fetus in cephalic presentation and a Bishop score of ≤ 6, were eligible for inclusion. Both nulliparous and parous women, and those with a previous Cesarean section (CS), were eligible. All women underwent transvaginal ultrasound assessment before IOL admission, and cervical length and LUS thickness were measured offline after delivery. Maternal and obstetric characteristics and Bishop score were recorded. The main outcome was the overall rate of CS after IOL, and secondary outcomes were CS for either failure to progress in the active phase of labor or failed IOL, and CS for failed IOL only. Interobserver agreement for measurement of LUS thickness between two operators was assessed using the intraclass correlation coefficient (ICC) and Bland-Altman analysis with the ANOVA test to evaluate systematic bias. Univariable and multivariable analysis were employed to evaluate the relationship between clinical and sonographic characteristics and IOL outcomes.

RESULTS

Of 265 women included in the analysis, 195 (73.6%) had a vaginal delivery and 70 (26.4%) required a CS after IOL. Reproducibility analysis showed excellent interobserver agreement for the measurement of LUS thickness (ICC, 0.96 (95% CI, 0.93-0.98)). On Bland-Altman analysis, the mean difference in LUS thickness between the two operators was 0.15 mm (95% limits of agreement, -1.84 to 2.14 mm), and there was no evidence of systematic bias (ANOVA test, P = 0.46). Univariable analysis showed that LUS thickness was associated significantly with overall CS (P = 0.002), CS for failure to progress in the active phase of labor or failed IOL (P = 0.03) and CS for failed IOL (P = 0.037). On multivariable logistic regression analysis, LUS thickness was an independent predictive factor for overall CS (odds ratio (OR), 1.149 (95% CI, 1.031-1.281)) and CS for failure to progress in the active phase of labor or failed IOL (OR, 1.226 (95% CI, 1.039-1.445)).

CONCLUSIONS

In women undergoing IOL at term, measurement of LUS thickness is feasible and reproducible, and is associated significantly with IOL outcome. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Expected-value bias in mid-trimester preterm birth screening

OBJECTIVES

Cervical length (CL) measurement ≤ 25 mm on mid-trimester ultrasound scan is a known risk factor for preterm birth, for which vaginal progesterone is recommended. The aims of this study were to evaluate whether CL measurement is affected by observer bias and to assess the impact on short cervix prevalence of masking CL measurement during routine mid-trimester ultrasound scan.

METHODS

This was a flash study designed for a 2-month period (October and November 2018) at Cruces University Hospital (Bizkaia, Spain), in which all CL measurements from routine mid-trimester scans were masked. During the study period, there was no modification of the routine screening method, and women with a short cervix were prescribed 200 mg vaginal progesterone daily as per usual. The control group included women examined in a 2-month period (April and May 2018) prior to the study, in which CL measurements were taken as usual by a non-blinded operator. The primary outcome was the prevalence of short cervix in each group.

RESULTS

A total of 983 CL measurements were analyzed, including 457 in the blinded group and 526 in the control group. The prevalence of short cervix was 2.7% in the non-blinded group and 5.5% in the blinded group (P = 0.024). We identified a statistically significant difference in the incidence of CL of 24-25 mm between the two groups, with a lower prevalence in the non-blinded vs blinded group (0.6% vs 2.4%; P < 0.005). Moreover, the distribution of CL values was normal in the blinded group, in contrast to the non-blinded group, which was characterized by skewed distribution of CL values.

CONCLUSIONS

Expected-value bias exists and should be taken into account when measuring CL in mid-trimester preterm birth screening. Blinding has demonstrated to be an effective strategy to improve the performance of CL screening in clinical practice. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Early transcriptional responses in Solanum peruvianum and Solanum lycopersicum account for different acclimation processes during water scarcity events

Cultivated tomato Solanum lycopersicum (Slyc) is sensitive to water shortages, while its wild relative Solanum peruvianum L. (Sper), an herbaceous perennial small shrub, can grow under water scarcity and soil salinity environments. Plastic Sper modifies the plant architecture when suffering from drought, which is mediated by the replacement of leaf organs, among other changes. The early events that trigger acclimation and improve these morphological traits are unknown. In this study, a physiological and transcriptomic approach was used to understand the processes that differentiate the response in Slyc and Sper in the context of acclimation to stress and future consequences for plant architecture. In this regard, moderate (MD) and severe drought (SD) were imposed, mediating PEG treatments. The results showed a reduction in water and osmotic potential during stress, which correlated with the upregulation of sugar and proline metabolism-related genes. Additionally, the senescence-related genes FTSH6 protease and asparagine synthase were highly induced in both species. However, GO categories such as "protein ubiquitination" or "endopeptidase inhibitor activity" were differentially enriched in Sper and Slyc, respectively. Genes related to polyamine biosynthesis were induced, while several cyclins and kinetin were downregulated in Sper under drought treatments. Repression of photosynthesis-related genes was correlated with a higher reduction in the electron transport rate in Slyc than in Sper. Additionally, transcription factors from the ERF, WRKY and NAC families were commonly induced in Sper. Although some similar responses were induced in both species under drought stress, many important changes were detected to be differentially induced. This suggests that different pathways dictate the strategies to address the early response to drought and the consequent episodes in the acclimation process in both tomato species.

Low frequency of cytomegalovirus (CMV) disease despite high prevalence of CMV viraemia in patients with advanced HIV infection: a clinical and immunological 48-week follow-up study

OBJECTIVES

The aim of the study was to investigate the dynamics of cytomegalovirus (CMV) replication and CMV-specific immune response recovery after antiretroviral treatment (ART) initiation in patients with advanced HIV infection.

METHODS

A prospective observational study of patients with HIV infection and CD4 counts of < 100 cells/µL was carried out (September 2015 to July 2018). HIV viral load (VL), CD4 count and CMV VL were determined by quantitative polymerase chain reaction (PCR) at baseline and at 4, 12, 24 and 48 weeks, and CMV-specific immune response was determined by QuantiFERON-CMV assay at baseline and 48 weeks. All patients were started on ART but only those with CMV end-organ disease (EOD) received anti-CMV treatment.

RESULTS

Fifty-three patients with a median age of 43.6 [interquartile range (IQR) 36.7-52.4] years were included in the study. At baseline, the median CD4 count was 30 cells/µL (IQR 20-60 cells/µL) and the median HIV VL was 462 000 HIV-1 RNA copies/mL (IQR 186 000-1 300 000 copies/mL). At baseline, 32% patients had detectable CMV viraemia but none had detectable CMV viraemia at 48 weeks. Only one of 53 (1.9%) patients developed EOD during follow-up. Seven (13.2%) patients were lost to follow-up and six (11.3%) died; none of the deaths was related to CMV. Similar percentages of patients had a CMV-specific immune response at baseline (71.7%) and at 48 weeks (70.0%). The magnitude of this response tended to increase over time [median 1.63 (IQR 0.15-5.77) IU/mL at baseline vs. median 2.5 (IQR 0.1-8.325) IU/mL at 48 weeks; P = 0.11]. We did not find any risk factors associated with 48-week mortality.

CONCLUSIONS

Although the prevalence of CMV viraemia in patients with advanced HIV infection remains high, achieving a good immunological recovery through ART is enough to suppress CMV viraemia, without an increased risk of CMV EOD. The prevalence of a CMV-specific immune response was high and endured over time.

New approach for estimating risk of miscarriage after chorionic villus sampling

OBJECTIVE

To estimate the risk of miscarriage associated with chorionic villus sampling (CVS).

METHODS

This was a retrospective cohort study of women attending for routine ultrasound examination at 11 + 0 to 13 + 6 weeks' gestation at one of eight fetal-medicine units in Spain, Belgium and Bulgaria, between July 2007 and June 2018. Two populations were included: (1) all singleton pregnancies undergoing first-trimester assessment at Hospital Clínico Universitario Virgen de la Arrixaca in Murcia, Spain, that did not have CVS (non-CVS group); and (2) all singleton pregnancies that underwent CVS following first-trimester assessment at one of the eight participating centers (CVS group). We excluded pregnancies diagnosed with genetic anomalies or major fetal defects before or after birth, those that resulted in termination and those that underwent amniocentesis later in pregnancy. We used propensity score (PS) matching analysis to estimate the association between CVS and miscarriage. We compared the risk of miscarriage of the CVS and non-CVS groups after PS matching (1:1 ratio). This procedure creates two comparable groups balancing the maternal and pregnancy characteristics that are associated with CVS, in a similar way to that in which randomization operates in a randomized clinical trial.

RESULTS

The study population consisted of 22 250 pregnancies in the non-CVS group and 3613 in the CVS group. The incidence of miscarriage in the CVS group (2.1%; 77/3613) was significantly higher than that in the non-CVS group (0.9% (207/22 250); P < 0.0001). The PS algorithm matched 2122 CVS with 2122 non-CVS cases, of which 40 (1.9%) and 55 (2.6%) pregnancies in the CVS and non-CVS groups, respectively, resulted in a miscarriage (odds ratio (OR), 0.72 (95% CI, 0.48-1.10); P = 0.146). We found a significant interaction between the risk of miscarriage following CVS and the risk of aneuploidy, suggesting that the effect of CVS on the risk of miscarriage differs depending on background characteristics. Specifically, when the risk of aneuploidy is low, the risk of miscarriage after CVS increases (OR, 2.87 (95% CI, 1.13-7.30)) and when the aneuploidy risk is high, the risk of miscarriage after CVS is paradoxically reduced (OR, 0.47 (95% CI, 0.28-0.76)), presumably owing to prenatal diagnosis and termination of pregnancies with major aneuploidies that would otherwise have resulted in spontaneous miscarriage. For example, in a patient in whom the risk of aneuploidy is 1 in 1000 (0.1%), the risk of miscarriage after CVS will increase to 0.3% (0.2 percentage points higher).

CONCLUSIONS

The risk of miscarriage in women undergoing CVS is about 1% higher than that in women who do not have CVS, although this excess risk is not solely attributed to the invasive procedure but, to some extent, to the demographic and pregnancy characteristics of the patients. After accounting for these risk factors and confining the analysis to low-risk pregnancies, CVS seems to increase the risk of miscarriage by about three times above the patient's background risk. Although this is a substantial increase in relative terms, in pregnancies without risk factors for miscarriage, the risk of miscarriage after CVS remains low and similar to, or slightly higher than, that in the general population. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Predictive performance of PAMG-1 vs fFN test for risk of spontaneous preterm birth in symptomatic women attending an emergency obstetric unit: retrospective cohort study

OBJECTIVE

To compare the performance of the placental alpha microglobulin-1 (PAMG-1) and fetal fibronectin (fFN) tests for the prediction of spontaneous preterm delivery in patients presenting to an emergency obstetric unit with threatened preterm labor, by conducting a retrospective audit of patient medical records from separate 1-year periods during which either fFN or PAMG-1 was used as the standard-of-care biochemical test.

METHODS

This was a retrospective cohort study based on chart review of electronic medical records of women with threatened preterm labor presenting at a level-III maternity hospital over two different periods: (1) the 'baseline' period (year 2012), during which the qualitative fFN test with a cut-off of 50 ng/mL was used as the standard-of-care biochemical test for the risk assessment of preterm delivery, and (2) the 'comparative' period (year 2016), during which the PAMG-1 test with a cut-off of 1 ng/mL was used as the standard-of-care biomarker test. Patients with a singleton pregnancy between 24 + 0 and 34 + 6 weeks' gestation with symptoms of early preterm labor, clinically intact membranes and cervical dilatation < 3 cm, who did not have a medically indicated preterm delivery within 14 days of testing, were selected for chart review and included in the analysis. Key parameters used for the analysis were biochemical test results, time of testing and time of delivery. Positive predictive value (PPV), negative predictive value (NPV), sensitivity, specificity, and positive and negative likelihood ratios (LR+ and LR-) for the prediction of spontaneous preterm delivery ≤ 7 and ≤ 14 days of presentation were calculated for the PAMG-1 and fFN tests.

RESULTS

Four hundred and twenty patients were identified as having presented with threatened preterm labor during the baseline period, of whom 378 (90.0%) met the eligibility criteria. Of these, 38 (10.1%) were fFN positive and 10 (2.6%) had spontaneous preterm delivery ≤ 7 days of presentation. PPV, NPV, LR+ and LR- of fFN were 7.9%, 97.9%, 3.2 and 0.8, respectively, for spontaneous preterm delivery ≤ 7 days. Four hundred and ten patients were identified as having presented with threatened preterm labor during the comparative period and 367 (89.5%) subjects met the eligibility criteria. Of these, 17 (4.6%) were PAMG-1 positive and 12 (3.3%) had spontaneous preterm delivery ≤ 7 days of presentation. PAMG-1 PPV and NPV were 35.3% and 98.3%, respectively, and LR+ and LR- were 16.1 and 0.5, respectively, for spontaneous preterm delivery ≤ 7 days.

CONCLUSIONS

Before switching to PAMG-1, fFN was the standard-of-care test for the risk assessment of spontaneous preterm delivery. This retrospective audit of each test's performance over separate 1-year periods shows that we were more than twice as likely to get a positive fFN test than a positive PAMG-1 test, while the rate of discharging women who ultimately delivered spontaneously within 14 days of testing was not affected. Furthermore, a positive PAMG-1 test was more than four times more reliable than a positive fFN test in predicting imminent spontaneous preterm delivery. The use of a more reliable biomarker that is associated with fewer false-positive results could lead to a reduction in unnecessary admissions, interventions and use of hospital resources. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Treatment options and predictive factors for recurrence and cancer-specific mortality in bladder cancer after renal transplantation: A multi-institutional analysis

OBJECTIVES

Bladder cancer (BC) in the transplanted population can represent a challenge owing to the immunosuppressed state of patients and the higher rate of comorbidities. The objective was to analyze the treatment of BC after renal transplant (RT), focusing on the mode of presentation, diagnosis, treatment options and predictive factors for recurrence.

MATERIAL AND METHODS

We conducted an observational prospective study with a retrospective analysis of 88 patients with BC after RT at 10 European centers. Clinical and oncologic data were collected, and indications and results of adjuvant treatment reviewed. The Kaplan-Meier method and uni- and multivariate Cox regression analyses were performed.

RESULTS

A total of 10,000 RTs were performed. Diagnosis of BC occurred at a median of 73 months after RT. Median follow-up was 126 months. Seventy-one patients (81.6%) had non-muscle invasive bladder cancer, of whom 29 (40.8%) received adjuvant treatment; of these, six (20.6%) received bacillus Calmette-Guérin and 20 (68.9%) mitomycin C. At univariate analysis, patients who received bacillus Calmette-Guérin had a significantly lower recurrence rate (P=.043). At multivariate analysis, a switch from immunosuppression to mTOR inhibitors significantly reduced the risk of recurrence (HR 0.24, 95% CI: 0.053-0.997, P=.049) while presence of multiple tumors increased it (HR 6.31, 95% CI: 1.78-22.3, P=.004). Globally, 26 patients (29.88%) underwent cystectomy. No major complications were recorded. Overall mortality (OM) was 32.2% (28 patients); the cancer-specific mortality was 13.8%.

CONCLUSIONS

Adjuvant bacillus Calmette-Guérin significantly reduces the risk of recurrence, as does switch to mTOR inhibitors. Multiple tumors increase the risk.

Experience in the treatment of osseous hydatidosis

Osseous hydatidosis is a very uncommon disease which often recurs after treatment. There is no well-established effective method of management. Radical excision may produce serious mutilation and often fails to control the disease. We have used oral mebendazole as adjuvant treatment in four patients. Two also underwent radical excision, one had received limited excision elsewhere and the other did not have operative treatment. The patients who underwent radical excision and the other who did not have an operation became and remain free of symptoms and are serologically negative.A combination of excision and treatment with mebendazole may have a role in the management of this complex disease.

Diagnosis and treatment for clinically localized prostate cancer. Adherence to the European Association of Urology clinical guidelines in a nationwide population-based study - GESCAP group

OBJECTIVE

To assess the adherence to European Association of Urology (EAU) guidelines in the management of prostate cancer (PCa) in Spain.

PATIENTS AND METHODS

Epidemiological, population-based, study including a national representative sample of 3,918 incident patients with histopathological confirmation during 2010; 95% of the patient's sample was followed up for at least one year. Diagnosis along with treatment related variables (for localized PCa -low, intermediate, high and locally-advanced by D'Amico risk stratification) was recorded. Differences between groups were tested with Chi-squared and Kruskal-Wallis tests.

RESULTS

Mean (SD) age of PCa patients was 68.48 (8.18). Regarding diagnostic by biopsy procedures, 64.56% of all patients had 8-12 cores in first biopsy and 46.5% of the patients over 75 years, with PSA<10ng/mL were biopsied. Staging by Computer Tomography (CT) or Bone Scan (BS) was used for determining tumor extension in 60.09% of high-risk cases and was applied differentially depending on patients' age; 3,293 (84.05%) patients received a treatment for localized PCa. Radical prostatectomy was done in 1,277 patients and 206 out of these patients also had a lymphadenectomy, being 4.64% low-risk, 22.81% intermediate-risk and 36.00% high-risk patients; 86.08% of 1,082 patients who had radiotherapy were treated with 3D or IMRT and 35.77% received a dose ≥75Gy; 419 patients were treated with brachytherapy (BT): 54.81% were low-risk patients, 22.84% intermediate-risk and 12.98% high-risk. Hormonotherapy (HT, n=521) was applied as single therapy in 9.46% of low-risk and 17.92% of intermediate-risk patients. Additionally, HT was combined with RT in 14.34% of lower-risk patients and 58.26% of high-risk patients, and 67.19% low-intermediate risk with RT and/or BT received neoadjuvant/concomitant/adjuvant HT. Finally, 83.75% of high-risk patients undergoing RT and/or BT also received HT.

CONCLUSIONS

Although EAU guidelines for PCa management are easily available in Europe, the adherence to their recommendations is low, finding the highest discrepancies in the need for a prostate biopsy and the diagnostic methods. Improve information and educational programs could allow a higher adherence to the guidelines and reduce the variability in daily practice. (Controlled-trials.com: ISRCTN19893319).

Levofloxacin versus azithromycin for treating legionella pneumonia: a propensity score analysis

OBJECTIVES

Concerns have arisen regarding the equivalence of levofloxacin and some macrolides for treating community-acquired legionella pneumonia (LP). We aimed to compare the outcomes of current patients with LP treated with levofloxacin, azithromycin and clarithromycin.

METHODS

Observational retrospective multicentre study of consecutive patients with LP requiring hospitalization (2000-2014) conducted in two hospitals. The primary outcome assessed was 30-day mortality. To control for confounding, therapy was assessed by multivariate analysis.

RESULTS

We documented 446 patients with LP, of which 175 were treated with levofloxacin, 177 with azithromycin and 58 with clarithromycin. No significant differences in time to defervescence (2 (interquartile range (IQR) 1-4) versus 2 (IQR 1-3) days; p 0.453), time to achieve clinical stability (3 (2-5) versus 3 (2-5) days; p 0.486), length of intravenous therapy (3 (2-5.25) versus 4 (3-6) days; p 0.058) and length of hospital stay (7 (5-10) versus 6 (5-9) days; p 0.088) were found between patients treated with levofloxacin and those treated with azithromycin. Patients treated with clarithromycin had longer intravenous antibiotic treatment (3 (2-5.25) versus 5 (3-6.25) days; p 0.002) and longer hospital stay (7 (5-10) versus 9 (7-14) days; p 0.043) compared with those treated with levofloxacin. The overall mortality was 4.3% (19 patients). Neither univariate nor multivariate analysis showed a significant association of levofloxacin versus azithromycin on mortality (4 (2.3%) versus 9 (5.1%) deaths; p 0.164). The results did not change after incorporation of the propensity score into the models.

CONCLUSIONS

In our study, no significant differences in most outcomes were found between patients treated with levofloxacin and those treated with azithromycin. Due to the small number of deaths, results regarding mortality should be interpreted with caution.

Prevalence of endometriosis in women with systemic lupus erythematosus and Sjögren's syndrome

Endometriosis is associated with a number of immunologic alterations. It has been suggested that autoimmune disorders could be more frequent in patients with endometriosis. The aim of this study is to ascertain whether the prevalence of two well-known autoimmune diseases [systemic lupus erythematosus (SLE) and Sjögren's syndrome (SS)] is increased in women with endometriosis. The clinical charts of four different populations assisted at the same hospital were manually revised: (i) SLE population ( n = 120), (ii) SS ( n = 22), (iii) endometriosis ( n = 342) and (iv) control population ( n = 501 consecutive unselected asymptomatic women). Among SLE women, the prevalence of endometriosis was 1.67% (2/120), similar to the 4.39% prevalence of the control group (22/501), the OR being 0.37 [95%CI 0.09—1.59]. Among SS women, the prevalence of endometriosis was 9.09 (2/22), also similar to the control group OR 2.17 [95%CI 0.48—9.90]. In the same way, when comparing endometriosis cases with asymptomatic women, similar frequencies of SLE (0.58% and 0.2%) and SS were found (0% and 0%). Women with endometriosis do not have an increased prevalence of SLE or SS. Lupus (2007) 16, 736—740.

Determination of neutrophil CD64 expression as a prognostic biomarker in patients with community-acquired pneumonia

The expression of CD64 in neutrophils (nCD64) has shown utility in the diagnosis of sepsis. The aim of this study was to assess the usefulness of nCD64 expression to identify patients with community-acquired pneumonia (CAP) at risk of a poor outcome. A prospective study of nCD64 expression (determined by flow cytometry) in patients with CAP was performed. The sensitivity/specificity of nCD64 in predicting poor outcome [defined as intensive care unit (ICU) admission and/or clinical deterioration after arrival at the emergency department] was calculated. Eighty-three adults with CAP were included; 14.5 % had septic shock, 19.3 % required ICU admission, and 10.8 % presented clinical deterioration after admission. The mean of the median fluorescence intensity (MFI) of nCD64 expression was 1140 (±1097). Patients with nCD64 expression ≥2700 MFI had more clinical deterioration (36.4 vs. 7.2 %, p = 0.015) and more ICU admission (45.5 vs. 14.5 %, p = 0.028). To identify clinical deterioration and ICU admission, nCD64 expression showed a sensitivity of 44.4 and 33.3 % and a specificity of 90.1 and 90.8 %, respectively. The addition of nCD64 expression to the Pneumonia Severity Index and CURB-65 severity scores did not improve the accuracy of predicting these outcomes. Although nCD64 expression is associated with an increased risk of ICU admission or clinical deterioration after admission, its accuracy in predicting these poor outcomes is modest and does not significantly improve the predictive ability of the PSI and CURB-65 severity scores.

Treatment trends for clinically localised prostate cancer. National population analysis: GESCAP group

OBJECTIVES

To describe the established therapies for localised prostate cancer (PC) in Spain and to assess compliance with the 2010 UAE guidelines.

PATIENTS AND METHODS

This was an epidemiological, observational, prospective and multicentre study. Of the 3,918 patients diagnosed with PC during 2010, only those patients with localised PC were included. Follow-up was ultimately conducted for a minimum of one year from the diagnosis for 3,713 patients (94.77%). The treatment groups assessed were as follows: radical prostatectomy, radiation therapy, hormone therapy, brachytherapy, active surveillance or observation and experimental local treatment (cryotherapy or other treatment). Compliance with the recommendations of the EAU guidelines was studied, describing the treatment groups according to D'Amico risk stratification criteria (localised [low, intermediate and high risk] and locally advanced), age, PSA and Gleason score.

RESULTS

By applying the D'Amico criteria, we included 3,641 (92.93%) patients. Based on the UAE recommendations: 1) 68.87% of the patients at low-intermediate risk aged≤65 years underwent radical prostatectomy; 2) 34.51% of the patients>65 years at high risk with locally advanced disease were administered radiation therapy and hormone therapy; 3) 30.36% of the patients at high risk with locally advanced disease were only treated with hormone therapy; 4) 15.20% of the patients at low risk were only treated with brachytherapy; 5) active surveillance or observation was selected for 2.44% of the patients aged≤65 years and for 10.63% of the patients at low-intermediate risk who were>65 years. Lastly, 86.5% of the patients at low risk underwent a single treatment, and 43.62% of the patients at high risk with locally advanced disease underwent combined treatments.

CONCLUSIONS

This is the first national European study to evaluate the therapeutic management of localised PC based on the risk group to which the patient belonged. Most young patients (≤65 years) with low-intermediate risk localised PC were treated with surgery, which adheres to the recommendations of the 2010 UAE guidelines. Various therapeutic combinations have been employed for patients with high-risk, locally advanced localised tumours, revealing the need for a multidisciplinary approach (Controlled-trials.com number: ISRCTN19893319).

The effectiveness of electrocautery ablation for the treatment of high-grade anal intraepithelial neoplasia in HIV-infected men who have sex with men

OBJECTIVES

Electrocautery is one of the main treatment options for high-grade anal intraepithelial neoplasia (HGAIN). However, data regarding its efficacy are scarce. The aim of the study was to evaluate the effectiveness of electrocautery for the treatment of HGAIN.

METHODS

An observational study of HIV-infected men who have sex with men (MSM) who underwent screening for anal dysplasia was carried out. The on-treatment effectiveness of electrocautery was evaluated (according to biopsy findings measured 6-8 weeks after treatment) in patients with HGAIN. A complete response was defined as resolution of anal intraepithelial neoplasia (AIN), a partial response as regression to low-grade AIN and recurrence as biopsy-proven HGAIN during follow-up.

RESULTS

From May 2009 to November 2014, 21.9% (126 of 576) of patients screened were found to have HGAIN. Electrocautery effectiveness was evaluated in 83 patients. A complete response was observed in 27 patients [32.5%; 95% confidence interval (CI) 23.4-53.2%], a partial response in 28 patients (33.7%; 95% CI 24.5-44.4%) and persistence in 28 patients (33.7%; 95% CI 24.5-44.4%). The patients with the most successful results (81.8%) required two to four sessions of electrocautery. After a mean follow-up of 12.1 months, 14 of 55 patients with a response (25.4%; 95% CI 15.8-38.3%) developed recurrent HGAIN within a mean time of 29.9 months (95% CI 22-37.7 months). No patient progressed to invasive cancer during the study or developed serious adverse events after treatment. No factors associated with poor response or recurrences were observed.

CONCLUSIONS

Although electrocautery is the standard treatment for anal dysplasia, almost 50% of patients with HGAIN in our study did not respond or relapsed. New treatment strategies are necessary to optimize the management of anal dysplasia.

Radionuclide biological half-life values for terrestrial and aquatic wildlife

The equilibrium concentration ratio is typically the parameter used to estimate organism activity concentrations within wildlife dose assessment tools. Whilst this is assumed to be fit for purpose, there are scenarios such as accidental or irregular, fluctuating, releases from licensed facilities when this might not be the case. In such circumstances, the concentration ratio approach may under- or over-estimate radiation exposure depending upon the time since the release. To carrying out assessments for such releases, a dynamic approach is needed. The simplest and most practical option is representing the uptake and turnover processes by first-order kinetics, for which organism- and element-specific biological half-life data are required. In this paper we describe the development of a freely available international database of radionuclide biological half-life values. The database includes 1907 entries for terrestrial, freshwater, riparian and marine organisms. Biological half-life values are reported for 52 elements across a range of wildlife groups (marine = 9, freshwater = 10, terrestrial = 7 and riparian = 3 groups). Potential applications and limitations of the database are discussed.

Congenital malformations, chromosomal abnormalities and perinatal results in IVF/ICSI newborns resulting from very poor quality embryos: a case-control study

AIMS

To explore whether the transfer of very poor quality (VPQ) embryos is associated with an increase in congenital malformations or perinatal problems.

METHODS

In this retrospective case-control study, 74 children conceived by in vitro fertilization (IVF) and/or intracytoplasmic sperm injection (ICSI) resulting exclusively from the transfer of VPQ embryos were compared with 1,507 children born after the transfer of top morphological quality (TQ) embryos over the same period of time in the same centers.

RESULTS

The prevalence of birth defects in children resulting from VPQ embryos was 1.35% (1/74), similar to the 1.72% (26/1,507) when only TQ embryos were transferred; the rate of chromosomal abnormalities detected was also similar (0.0 vs. 0.4%), as was perinatal mortality. After correcting for multiplicity (higher in the TQ group), the aforementioned parameters remained similar in the two groups.

CONCLUSION

Congenital malformations and perinatal complications do not seem to be more common in children born after transfer of VPQ embryos in IVF/ICSI cycles. Given our preliminary data, which need to be confirmed in much larger studies, when only VPQ embryos are available for transfer in IVF/ICSI cycles, we do not believe that they should be discarded with the intention of avoiding birth defects or perinatal complications.

Liver stiffness and aspartate aminotransferase levels predict the risk for liver fibrosis progression in hepatitis C virus/HIV-coinfected patients

OBJECTIVES

The aim of the study was to investigate liver fibrosis outcome and the risk factors associated with liver fibrosis progression in hepatitis C virus (HCV)/HIV-coinfected patients.

METHODS

We prospectively obtained liver stiffness measurements by transient elastography in a cohort of 154 HCV/HIV-coinfected patients, mostly Caucasian men on suppressive antiretroviral treatment, with the aim of determining the risk for liver stiffness measurement (LSM) increase and to identify the predictive factors for liver fibrosis progression. To evaluate LSM trends over time, a linear mixed regression model with LSM level as the outcome and duration of follow-up in years as the main covariate was fitted.

RESULTS

After a median follow-up time of 40 months, the median increase in LSM was 1.05 kPa/year [95% confidence interval (CI) 0.72-1.38 kPa/year]. Fibrosis stage progression was seen in 47% of patients, and 17% progressed to cirrhosis. Aspartate aminotransferase (AST) levels and liver fibrosis stage at baseline were identified as independent predictors of LSM change. Patients with F3 (LSM 9.6-14.5 kPa) or AST levels ≥ 64 IU/L at baseline were at higher risk for accelerated LSM increase (ranging from 1.45 to 2.61 kPa/year), whereas LSM change was very slow among patients with both F0-F1 (LSM  ≤ 7.5 kPa) and AST levels ≤ 64 IU/L at baseline (0.34 to 0.58 kPa/year). An intermediate risk for LSM increase (from 0.78 to 1.03 kPa/year) was seen in patients with F2 (LSM 7.6-9.5 kPa) and AST baseline levels ≤  64 IU/L.

CONCLUSIONS

AST levels and liver stiffness at baseline allow stratification of the risk for fibrosis progression and might be clinically useful to guide HCV treatment decisions in HIV-infected patients.

Impact of influenza season and environmental factors on the clinical presentation and outcome of invasive pneumococcal disease

Influenza and meteorological factors have been associated with increases in the incidence of invasive pneumococcal disease (IPD). However, scant data regarding the impact of influenza and the environment on the clinical presentation of IPD are available. An observational study of all adults hospitalized with IPD was performed between 1996 and 2012 in our hospital. The incidence of IPD correlated with the incidence rates of influenza and with environmental data. A negative binominal regression was used to assess the relationship between these factors. Clinical presentation of IPD during the influenza and non-influenza periods was compared. During the study, 1,150 episodes of IPD were diagnosed. After adjusting for confounding variables, factors correlating with the rates of IPD were the incidence of influenza infection (IRR 1.229, 95% CI 1.025-1.472) and the average ambient temperature (IRR 0.921, 95% CI 0.88-0.964). Patients with IPD during the influenza period had a worse respiratory status. A greater proportion of patients had respiratory failure (45.6% vs 52%, p = 0.032) and higher requirements for ICU admission (19.3% vs 24.7%, p = 0.018) and mechanical ventilation (11% vs 15.1%, p = 0.038). When we stratified by invasiveness of pneumococcal serotypes and the presence of comorbid conditions, the increase in the severity of clinical presentation was focused on healthy adults with IPD caused by nonhighly invasive serotypes. Beyond the increase in the burden of IPD associated with influenza, a more severe clinical pattern of pneumococcal disease was observed in the influenza period. This effect varied according to pneumococcal serotype, host comorbidities, and age.

[Intravenous infusion of adult adipose tissue stem cells for repairing spinal cord ischaemic lesions. An experimental study on animals]

OBJECTIVE

To assess if a peripheral intravenous infusion of adipose tissue stem cells (ATSC), after an ischemic spinal cord injury can promote selective cell migration and cell survival in the damaged neural tissue. ANIMALS AND METHOD: An ischaemic spinal cord injury was provoked by trapping the abdominal aorta for 20 minutes in 11 male New Zealand rabbits (2.5±0.5kg). They were randomised into two groups: one group (n=5) received an intravenous transfusion of 10±2×10(6) ATSC at 24 hours from the injury, and the control group (n=6) were only given the vehicle. The functional status was assessed, using the Tarlov scale at 24h, and 7 and 14 days. The animals were sacrificed at 14 days and a histological and immunohistochemical study was performed.

RESULTS

Complete paraplegia was achieved in both groups. There were no significant differences as regards neurological recovery, which was nil in both cases. In the histological and immunohistochemical study, it was tested to see if there was any bromodeoxyuridine-marked ATSC in the area of the lesion, but there was only a small amount.

CONCLUSION

ATSC are able to migrate and survive in the injured spinal cord after aortic ischaemia after they have been administered intravenously. Intravenous infusion is a harmless procedure with no side effect. No neurological recovery was achieved.

Impact of the emergence of non-vaccine pneumococcal serotypes on the clinical presentation and outcome of adults with invasive pneumococcal pneumonia

The introduction of the 7-valent pneumococcal conjugate vaccine in children has led to a change in the pattern of pneumococcal serotypes causing pneumococcal disease. The aim of this study was to compare the clinical presentation and outcome of invasive pneumococcal pneumonia (IPP) in adults between the pre and post-vaccine era. We have conducted an observational study of all adults hospitalized with IPP, from 1996 to 2001 (pre-vaccine period), and from 2005 to 2009 (post-vaccine period). Incidence, serotype distribution and clinical data were compared between both periods. A total of 653 episodes of IPP were diagnosed. The overall incidence of IPP increased from 14.2 to 17.9 cases per 100 000 population-year (p 0.003). In the post-vaccine period IPP caused by vaccine serotypes decreased (-36%; 95% CI, -52 to -15) while IPP caused by non-vaccine serotypes increased (71%; 95% CI, 41-106). IPP in the post-vaccine period was associated with higher rates of septic shock (19.1% vs. 31.1%, p <0.001). Among patients aged 50-65 years there was a trend towards a greater proportion of case-fatalities (11.6-23.5%, p 0.087). Independent risk factors for septic shock were IPP caused by serotype 3 (OR 2.38; 95% CI, 1.16-4.87) and serotype 19A (OR 6.47, 95% CI, 1.55-27). Serotype 1 was associated with a lower risk of death (OR 0.1; 95% CI, 0.01-0.78). In conclusion, the incidence of IPP in the post-vaccine period has increased in our setting, it is caused mainly by non-vaccine serotypes and it is associated with higher rates of septic shock.

Prognostic value of serum progesterone and LH values on the day of hCG administration in IUI GnRH antagonist cycles

OBJECTIVE

to evaluate the effect of LH surge and progesterone rise in IUI cycles under gonadotropin stimulation with GnRH antagonist coadministration on pregnancy rates (PR).

STUDY DESIGN

The population under study consisted of 152 women prospectively studied and subjected to IUI.

RESULTS

The higher the progesterone cutoff value, the lower the PR were 26.5% and 10.9% when the cutoff was 1 ng/mL, 26.0% and 8.6% when the cutoff was 1.2 ng/mL, 25.6% and 7.1% when the cutoff was 1.4 ng/mL and 25.3% and 0% when the cutoff was 1.6 ng/mL.

CONCLUSION

In IUI cycles under GnRH antagonist coadministration, serum progesterone levels over 1.0 ng/mL are associated with lower PR, the higher the progesterone levels, the lower the PR.

Late-life obesity is associated with smaller global and regional gray matter volumes: a voxel-based morphometric study

OBJECTIVE:

Obesity adversely affects frontal lobe brain structure and function. Here we sought to show that people who are obese versus those who are of normal weight over a 5-year period have differential global and regional brain volumes.

DESIGN:

Using voxel-based morphometry, contrasts were done between those who were recorded as being either obese or of normal weight over two time points in the 5 years prior to the brain scan. In a post-hoc preliminary analysis, we compared scores for obese and normal weight people who completed the trail-making task.

SUBJECTS:

A total of 292 subjects were examined following exclusions (for example, owing to dementia, stroke and cortical infarcts) from the Prospective Investigation of the Vasculature in Uppsala Seniors cohort with a body mass index of normal weight (<25 kg m⁻²) or obese (⩾30 kg m⁻²).

RESULTS:

People who were obese had significantly smaller total brain volumes and specifically, significantly reduced total gray matter (GM) volume (GMV) (with no difference in white matter or cerebrospinal fluid). Initial exploratory whole brain uncorrected analysis revealed that people who were obese had significantly smaller GMV in the bilateral supplementary motor area, bilateral dorsolateral prefrontal cortex (DLPFC), left inferior frontal gyrus and left postcentral gyrus. Secondary more stringent corrected analyses revealed a surviving cluster of GMV difference in the left DLPFC. Finally, post-hoc contrasts of scores on the trail-making task, which is linked to DLPFC function, revealed that obese people were significantly slower than those of normal weight.

CONCLUSION:

These findings suggest that in comparison with normal weight, people who are obese have smaller GMV, particularly in the left DLPFC. Our results may provide evidence for a potential working memory mechanism for the cognitive suppression of appetite that may lower the risk of developing obesity in later life.

Complete switch to everolimus in long-term kidney transplants: evolution of the renal function

INTRODUCTION

The use of M-tor inhibitors plus withdrawal of anticalcineurins after 3 months of posttransplantation is usually linked to improvements in renal function. The long-term effects of substitution of anticalcineurinis by everolimus remain unknown. The aim in this study was to evaluate the evolution of renal function and the proteinuria after a complete switch of long-term functioning allograft patients to everolimus. We treated 30 renal transplanted patients with everolimus, at a mean time posttransplantation of 123.8 +/- 74.2 months. The 27 patients, including 17 treated with tacrolimus and 10 with cyclosporine, who were controlled for at least 6 months were included in this study. Seventeen of them were diagnosed to display chronic allograft nephropathy (CAN).

RESULTS

The patients with CAN showed a basal creatinine of 1.81 +/- 0.4; with after a year, 1.61 +/- 0.38; and after 2 years, 1.56 +/- 0.49 mg/dL (P < .05). No significant changes were observed among patients without CAN: 1.1 +/- 0.32, 0.97 +/- 0.15, and 0.97 +/- 0.15 mg/dL, respectively. In CAN patients, the protein/creatinine quotient was: basal = 0.30 +/- 0.13, one year = 0.63 +/- 0.68, and 2 years = 0.48 +/- 0.34. In the other patients the values were 0.2 +/- 0.07, 0.73 +/- 0.7, and 0.32 +/- 0.17, respectively, after a late switch to everolimus.

CONCLUSION

The improved renal function occurred mainly in patients with CAN. Patients who did not suffer from it showed a greater rise in proteinuria. Nevertheless, both groups experienced decreased proteinuria after 2 years.

Mycophenolate Mofetil Levels in Stable Kidney Transplant Recipients

The usefulness of mycophenolate mofetil (MMF) levels in stable kidney transplant patients is not well known. We measured MMF trough levels in 137 adult kidney recipients with more than 1 year of stable graft function. The MMF dose was adjusted according to hematological or gastrointestinal toxicity, it was 500 mg in 22 (16%) patients; 750 mg in 22 (16%); 1000 mg in 69 (50.5%); 1500 mg in 15 (11%); and 2000 mg in 9 (6.5%). We analyzed the total dose, virgule dose/kg, and MMF levels in relation to efficacy parameters (creatinine, proteinuria) and hematological toxicity (erythrocytes, leukocytes, and platelets) at the time of MMF level determinations and 3 months thereafter. Statistical analyses were performed with SSPS 12.0, including sensitivity and specificity analyses by ROC. Mean MMF levels were 3.68 mg/L (Pc25, 1.6-Pc75, 4.4 mg/L) with significant differences according to dose (P < .001). Trough MMF levels did not have discriminatory capacity in the area under the ROC for anemia, renal failure, or proteinuria at the time of determination or 3 months later. The percentage of patients without proteinuria was high among patients with MMF levels between 1.6 and 4.4 mg/L. The MMF levels were low in patients who had a major increase in creatinine (1.6 vs 3.8 mg/L, P < .05). In stable renal transplant patients the levels of MMF were related to the administered dose, and they are higher than those previously described in patients with less than a year follow-up with a functioning kidney. They did not have discriminatory value at the time of determination or 3 months later. Nevertheless, low MMF levels could help recognize patients at risk of developing chronic nephropathy.

Long-term outcome of a phase II study of weekly docetaxel with a short course of estramustine and enoxaparine in hormone-resistant prostate cancer patients

OBJECTIVE

The objective was to define the toxicity and activity of weekly docetaxel administered with a short course of estramustine and enoxaparine in patients with hormone-resistant prostate cancer (HRPC).

PATIENTS AND METHODS

Twenty-four patients were treated with the next regimen: weekly docetaxel 36 mg/m(2) iv for three consecutive weeks every 28 days, and estramustine 280 mg three times a day for three consecutive days beginning the day before docetaxel (days 1-3, 8-10 and 15-17). In order to prevent thromboembolic events, 40 mg of subcutaneous enoxaparine was administered daily sc on the same days as estramustine. Primary endpoints were: toxicity, especially the presence of thromboembolic events, PSA response rate and response in measurable disease. Secondary endpoints were: time to PSA progression and overall survival.

RESULTS

Nineteen of 24 patients (79.1%, 95% CI 71-87%) had a PSA response = or >50%. Four of the eleven patients with measurable disease had a partial response. The median time to PSA progression was 7 months (CI 95%: 6.5-9) and the median survival was 19 months (IC 95%: 11-24). Toxicity was manageable with no treatment- related mortality. Only two patients had grade 4 neutropenia. Two patients had thrombotic events, one deep venous thrombosis and one stroke. The main grade 3 non-haematologic toxicity was diarrhoea and asthenia, both in 25% of patients.

CONCLUSIONS

Weekly docetaxel with a short course of estramustine and enoxaparine is active and tolerable in HRPC patients. The observed incidence of thrombosis was lower than previously reported but the association of enoxaparine was not enough to completely prevent the thromboembolic events.