The effectiveness of cervical cerclage in twin pregnancies with a mid-trimester short cervix: A retrospective cohort study

OBJECTIVE

To analyze the effectiveness of cerclage in twin pregnancies with a short cervix.

STUDY DESIGN

Retrospective cohort study performed in two University Institutions in Valencia (Spain) with two different protocols for the management of asymptomatic dichorionic diamniotic twin pregnancies with mid-trimester cervical length ≤ 25 mm: treatment with indomethacin, antibiotics and cerclage (cerclage group) (N = 43) versus expectant management (control group) (N = 37).

RESULTS

The initial cervical length was similar in both groups but detection of a short cervix was performed earlier in the cerclage group (21.6 vs 24.1 weeks, p < 0.001). Women with cerclage had a greater pregnancy latency (12.5 vs. 7.7 weeks, p < 0.001); higher gestational age at delivery (34.1 vs. 31.8 weeks, p < 0.04); less spontaneous preterm birth (SPB) < 28 weeks (11.6 % vs 37.8 %, p < 0.009); higher birthweight (2145 vs 1733 g, p < 0.001); lower birthweight < 1500 g (12.5 % vs 40.0 %, p < 0.001); less admissions to the neonatal intensive care unit (NICU) (24.1 % vs 43.3 %, p < 0.03); shorter stay at NICU (25.6 vs 49.4 days, p < 0.02); lower respiratory distress requiring mechanical ventilation (14.9 % vs 36.5 %, p < 0.02); fewer patent ductus arteriosus (8.9 % vs 26.9 %, p < 0.008); and lower composite adverse neonatal outcome (26.6 % vs. 44.8 %, p < 0.03). Cerclage and gestational age at diagnosis were the only independent predictors of SPB < 32 and < 28 weeks by multivariate analysis. The cumulative data in the literature show promising beneficial effects of cerclage.

CONCLUSION

Our data suggest that cerclage in asymptomatic twin pregnancies with a short cervix may reduce the earliest SPB and may improve neonatal outcome.

Electrocardiographic markers of incident atrial fibrillation in patients with cryptogenic stroke

Funding Acknowledgements

Type of funding sources: None.

Introduction

Prolonged screening of AF in patients (pts) with cryptogenic stroke (CS) is recommended and electrocardiographic markers of atrial remodeling, like p-wave dispersion, have been described in literature. Electrocardiographic changes in pts with CS to predict AF in the follow up are not well-established.

Purpose

To identify ECG predictors of AF in a subset of pts with cryptogenic stroke.

Methods

We prospectively included consecutive pts admitted with CS. A surface 12-lead ECG was performed at admission, recorded at 25 mm/second and 10 mV/cm with commercially available imaging system. P-wave analysis of maximum (P max) and minimum (P min) duration, p-wave dispersion (PWD, defined as the difference between the P max and P min, being abnormal if &gt; 40 msec) and amplitude were evaluated by a two independent operator. P-wave axis was determined by an automated mode available in the equipment. ROC curve was analyzed to determine the optimal cut-off values.

Results

We enrolled 105 pts (55.2% males), with mean age of 68.18 ± 8.83 years, 79% had hypertension, 18.1% had diabetes, 44.8% with dyslipidemia, 21% current smokers.

During follow up period, 18 pts (17.1%) developed AF. We found that only PWD (AUC 0.706, IC95%: 0.564-0.848, p = 0.006) and P-wave axis (AUC 0.715, IC95%: 0.870-0.860, p = 0.004) were strong predictors of AF. PWD cut-off of 47.50 presented a sensitivity of 77.8% and specificity of 59.8% and P-wave axis cut off value of 75.50 had a specificity of 95.4%. Age (p = 0.032) and current smoking (p = 0.014) were associated with occurrence of AF during the follow up.

  Conclusion: PWD and P-wave axis predicted incident AF in this subset of pts with cryptogenic stroke. The ECG may be a toll to identify pts at risk of developing AF, although larger studies are needed to confirm these results. Abstract Figure.

A comparison of two mathematical models of the impact of mass drug administration on the transmission and control of schistosomiasis

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This paper compares two mathematical models describing the transmission dynamics of schistosome infection and the impact of mass drug administration.

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The models differ structurally in a number of ways, including the dynamics of the intermediate snail host and the treatment of adult worms within the human host.

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The models are validated against data taken from a mass-drug administration trial in Mozambique.

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The differences between the model predictions and the data are discussed in the context of the structural differences between the models.

The predictions of two mathematical models describing the transmission dynamics of schistosome infection and the impact of mass drug administration are compared. The models differ in their description of the dynamics of the parasites within the host population and in their representation of the stages of the parasite lifecycle outside of the host. Key parameters are estimated from data collected in northern Mozambique from 2011 to 2015. This type of data set is valuable for model validation as treatment prior to the study was minimal. Predictions from both models are compared with each other and with epidemiological observations. Both models have difficulty matching both the intensity and prevalence of disease in the datasets and are only partially successful at predicting the impact of treatment. The models also differ from each other in their predictions, both quantitatively and qualitatively, of the long-term impact of 10 years’ school-based mass drug administration. We trace the dynamical differences back to basic assumptions about worm aggregation, force of infection and the dynamics of the parasite in the snail population in the two models and suggest data which could discriminate between them. We also discuss limitations with the datasets used and ways in which data collection could be improved.

Reproductive outcomes after hysteroscopic metroplasty for women with dysmorphic uterus and recurrent implantation failure

BACKGROUND

The aim of this study was to assess the reproductive outcomes of women with recurrent implantation failure (RIF) after hysteroscopic metroplasty for dysmorphic uteri.

METHODS

This retrospective observational study included 190 women with a diagnosis of RIF. These patients were eligible for hysteroscopic metroplasty for dysmorphic uteri, including T-shaped uteri, between January 2008 and September 2015 at the Instituto Valenciano de Infertilidad (IVI) in Valencia, Spain.

RESULTS

The total clinical pregnancy rate, the live birth rate, and the abortion rate were 80.0% (152/190), 77.9% (147/190) and 8.9%, respectively. At 12 months, the clinical pregnancy rate was 76.3% (145/190) and at 6 months 50.5% (96/190). After the metroplasty, approximately 76% of all gravidities, were achieved during the first 12 months of follow-up. Within the first IVF cycle, pregnancy and live birth rates were 77.8% and 86.1%, respectively. The mean time to pregnancy was 6.5 months.

CONCLUSION

This study demonstrates that hysteroscopic metroplasty improves pregnancy and live birth rates for women with a history of recurrent implantation failure and dysmorphic uterus. However, conclusions must be taken carefully as this is an observational study. A prospective, randomized and controlled study is necessary to support these results.

Autologous cell therapy with CD133+ bone marrow-derived stem cells for refractory Asherman's syndrome and endometrial atrophy: a pilot cohort study

STUDY QUESTION

Could cell therapy using autologous peripheral blood CD133+ bone marrow-derived stem cells (BMDSCs) offer a safe and efficient therapeutic approach for patients with refractory Asherman's syndrome (AS) and/or endometrial atrophy (EA) and a wish to conceive?

SUMMARY ANSWER

In the first 3 months, autologous cell therapy, using CD133+ BMDSCs in conjunction with hormonal replacement therapy, increased the volume and duration of menses as well as the thickness and angiogenesis processes of the endometrium while decreasing intrauterine adhesion scores.

WHAT IS KNOWN ALREADY

AS is characterized by the presence of intrauterine adhesions and EA prevents the endometrium from growing thicker than 5 mm, resulting in menstruation disorders and infertility. Many therapies have been attempted for these conditions, but none have proved effective.

STUDY DESIGN, SIZE, DURATION

This was a prospective, experimental, non-controlled study. There were 18 patients aged 30-45 years with refractory AS or EA were recruited, and 16 of these completed the study. Medical history, physical examination, endometrial thickness, intrauterine adhesion score and neoangiogenesis were assessed before and 3 and 6 months after cell therapy.

PARTICIPANTS/MATERIALS, SETTING, METHODS

After the initial hysteroscopic diagnosis, BMDSC mobilization was performed by granulocyte-CSF injection, then CD133+ cells were isolated through peripheral blood aphaeresis to obtain a mean of 124.39 million cells (range 42-236), which were immediately delivered into the spiral arterioles by catheterization. Subsequently, endometrial treatment after stem cell therapy was assessed in terms of restoration of menses, endometrial thickness (by vaginal ultrasound), adhesion score (by hysteroscopy), neoangiogenesis and ongoing pregnancy rate. The study was conducted at Hospital Clínico Universitario of Valencia and IVI Valencia (Spain).

MAIN RESULTS AND THE ROLE OF CHANCE

All 11 AS patients exhibited an improved uterine cavity 2 months after stem cell therapy. Endometrial thickness increased from an average of 4.3 mm (range 2.7-5) to 6.7 mm (range 3.1-12) ( ITALIC! P = 0.004). Similarly, four of the five EA patients experienced an improved endometrial cavity, and endometrial thickness increased from 4.2 mm (range 2.7-5) to 5.7 mm (range 5-12) ( ITALIC! P = 0.03). The beneficial effects of the cell therapy increased the mature vessel density and the duration and intensity of menses in the first 3 months, with a return to the initial levels 6 months after the treatment. Three patients became pregnant spontaneously, resulting in one baby boy born, one ongoing pregnancy and a miscarriage. Furthermore, seven pregnancies were obtained after fourteen embryo transfers, resulting in three biochemical pregnancies, one miscarriage, one ectopic pregnancy, one baby born and one ongoing pregnancy.

LIMITATIONS, REASONS FOR CAUTION

Limitations of this pilot study include the small sample size and the lack of control group.

WIDER IMPLICATIONS OF THE FINDINGS

This novel autologous cell therapy is a promising therapeutic option for patients with these incurable pathologies and a wish to conceive.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by the Spanish Ministry of Science and Innovation (SAF 2012-31017, Principal Investigator C.S.), Spanish Ministry of Health (EC11-299, Principal Investigator C.S.) and Regional Valencian Ministry of Education (PROMETEOII/2013/018, Principal Investigator C.S.). Four authors (X.S., I.C., A.P. and C.S.) are co-inventors of the patent resulting from this work (Application number: 62/013,121). S.C., C.A., F.R., J.F., J.P. and J.R. have no conflict of interest in relation to this work.

TRIAL REGISTRATION NUMBER

This study was registered with ClinicalTrials.gov (NCT02144987).

Molecular analysis of products of conception obtained by hysteroembryoscopy from infertile couples

PURPOSE

To analyze the molecular cytogenetic data obtained from products of conception (POC) obtained by selective biopsy of first trimester miscarriages and to estimate the rate of chromosomal anomalies in miscarriages from pregnancies achieved by natural conception (NC) or by assisted reproductive technology (ART) interventions.

METHODS

We used KaryoLite™ BoBs™ (PerkinElmer LAS, Wallac, Turku, Finland) technology to analyze 189 samples from ART or NC pregnancies.

RESULTS

All POC were successfully evaluated. A higher incidence of chromosomal abnormalities was observed in POC after ART using the patient's own oocytes than from NC pregnancies (62.7% vs. 40.6%; p < 0.05). The lowest incidence of chromosomal abnormalities was observed in POCs ART using donor eggs from women younger than 35 years (12.8%). No statistical differences in the percentage of abnormal miscarriages were observed in correlation with sperm concentration: a sperm concentration less than 5 million/mL produced 75% abnormal results and a concentration higher than 5 million/mL produced 51%.

CONCLUSIONS

POC analysis is essential to determine the cause of pregnancy loss. Using culture-independent molecular biology techniques to analyze POCs avoids limitations such as growth failure and reduces the time required for analysis. Selective biopsy of fetal tissue by hysteroembryoscopy avoids the risk of misdiagnosis due to maternal cell contamination. Our results show that maternal age, sperm quality, and ART-assisted pregnancies are risk factors for abnormal gestations.

Female overweight is not associated with a higher embryo euploidy rate in first trimester miscarriages karyotyped by hysteroembryoscopy

Overweight women (body mass index ≥ 25 kg/m(2)) present an embryo euploidy rate in first trimester miscarriages similar to normoweight controls after a selective biopsy and karyotyping of embryo and/or chorion samples taken by hysteroembryoscopy.

Human endometrial side population cells exhibit genotypic, phenotypic and functional features of somatic stem cells

During reproductive life, the human endometrium undergoes around 480 cycles of growth, breakdown and regeneration should pregnancy not be achieved. This outstanding regenerative capacity is the basis for women's cycling and its dysfunction may be involved in the etiology of pathological disorders. Therefore, the human endometrial tissue must rely on a remarkable endometrial somatic stem cells (SSC) population. Here we explore the hypothesis that human endometrial side population (SP) cells correspond to somatic stem cells. We isolated, identified and characterized the SP corresponding to the stromal and epithelial compartments using endometrial SP genes signature, immunophenotyping and characteristic telomerase pattern. We analyzed the clonogenic activity of SP cells under hypoxic conditions and the differentiation capacity in vitro to adipogenic and osteogenic lineages. Finally, we demonstrated the functional capability of endometrial SP to develop human endometrium after subcutaneous injection in NOD-SCID mice. Briefly, SP cells of human endometrium from epithelial and stromal compartments display genotypic, phenotypic and functional features of SSC.

Preliminary Results of the Mutational Analysis of the TP53 Gene in Women Diagnosed with Breast Cancer before the Age of 35 Years and Negative for BRCA1 and BRCA2 Mutations

Background: Early onset breast cancer is part of the tumor spectrum in the Li-Fraumeni syndrome (MIM 151623), which is associated with germ-line mutations in the TP53 gene. The aim of the study is to determine the presence of inherited mutations in TP53 in women with early onset breast cancer regardless of their family history and after having obtained a negative result for the BRCA1 and BRCA2 mutations. Patients and methods: We analyzed 41 women with breast cancer (BC) diagnosed before the age of 35 years and a negative result for the BRCA1 and BRCA2 genes (analyzed by direct sequencing and MLPA). Patients were classified according their family history in three groups: A) no family history of cancer (n=11); B) family history of breast/ovarian cancer (BC/OC) (n=22); C) family history of other neoplasms (pancreas, kidney, brain, leukemia) without fulfilling the classical Li-Fraumeni criteria (n=8). The analysis of the TP53 gene was carried out by PCR amplification and direct sequencing of the exons 4 to 10. Analysis of the remaining exons, the 5' and 3' UTR regions of the gene, and the detection of large rearrangements are in progress. Results: Among the 41 women we identified two (4.8%) deleterious mutations, and both were observed in group C (2/8, 25%): c.375G&gt;A in exon 4 (splicing mutation) and c.524G&gt;A in exon 5 (p.R175H). Conclusions: These preliminary results suggest that, after a negative result in the analysis of the BRCA1 and BRCA2 genes, TP53 mutations may play a relevant etiological role in the genetic predisposition of early onset BC, especially in those families with presence of different neoplasms

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4072.

Location of lacunar infarcts correlates with cognition in a sample of non-disabled subjects with age-related white-matter changes: the LADIS study

OBJECTIVES

In cerebral small vessel disease, white-matter hyperintensities (WMH) and lacunes are both related to cognition. Still, their respective contribution in older people remains unclear. The purpose of this study is to assess the topographic distribution of lacunes and determine whether it has an impact on cognitive functions in a sample of non-disabled patients with age-related white-matter changes.

METHODS

Data were drawn from the baseline evaluation of the LADIS (Leucoaraioisis and Disability study) cohort of non-disabled subjects beyond 65 years of age. The neuropsychological evaluation was based on the Mini Mental Status Examination (MMSE), a modified Alzheimer Diseases Assessment Scale for global cognitive functions, and compound Z scores for memory, executive functions, speed and motor control. WMH were rated according to the Fazekas scale; the number of lacunes was assessed in the following areas: lobar white matter, putamen/pallidum, thalamus, caudate nucleus, internal/external capsule, infratentorial areas. An analysis of covariance was performed after adjustment for possible confounders.

RESULTS

Among 633 subjects, 47% had at least one lacune (31% at least one within basal ganglia). The presence of lacunes in the thalamus was associated with lower scores of MMSE (beta = -0.61; p = 0.043), and worse compound scores for speed and motor control (beta = -0.25; p = 0.006), executive functions (beta = -0.19; p = 0.022) independently of the cognitive impact of WMH. There was also a significant negative association between the presence of lacunes in putamen/pallidum and the memory compound Z score (beta = -0.13; p = 0.038). By contrast, no significant negative association was found between cognitive parameters and the presence of lacunes in internal capsule, lobar white matter and caudate nucleus.

CONCLUSION

In non-disabled elderly subjects with leucoaraisosis, the location of lacunes within subcortical grey matter is a determinant of cognitive impairment, independently of the extent of WMH.

VITATOPS, the VITAmins TO prevent stroke trial: rationale and design of a randomised trial of B-vitamin therapy in patients with recent transient ischaemic attack or stroke (NCT00097669) (ISRCTN74743444)

BACKGROUND

Epidemiological studies suggest that raised plasma concentrations of total homocysteine (tHcy) may be a common, causal and treatable risk factor for atherothromboembolic ischaemic stroke, dementia and depression. Although tHcy can be lowered effectively with small doses of folic acid, vitamin B(12) and vitamin B(6), it is not known whether lowering tHcy, by means of B vitamin therapy, can prevent stroke and other major atherothromboembolic vascular events.

AIM

To determine whether the addition of B-vitamin supplements (folic acid 2 mg, B(6) 25 mg, B(12) 500 microg) to best medical and surgical management will reduce the combined incidence of stroke, myocardial infarction (MI) and vascular death in patients with recent stroke or transient ischaemic attack (TIA) of the brain or eye.

DESIGN

A prospective, international, multicentre, randomised, double blind, placebo-controlled clinical trial.

SETTING

One hundred and four medical centres in 20 countries on five continents.

SUBJECTS

Eight thousand (6600 recruited as of 5 January, 2006) patients with recent (<7 months) stroke (ischaemic or haemorrhagic) or TIA (brain or eye).

RANDOMISATION

Randomisation and data collection are performed by means of a central telephone service or secure internet site.

INTERVENTION

One tablet daily of either placebo or B vitamins (folic acid 2 mg, B(6) 25 mg, B(12) 500 mug).

PRIMARY OUTCOME

The composite of stroke, MI or death from any vascular cause, whichever occurs first. Outcome and serious adverse events are adjudicated blinded to treatment allocation.

SECONDARY OUTCOMES

TIA, unstable angina, revascularisation procedures, dementia, depression. STATISTICAL POWER: With 8000 patients followed up for a median of 2 years and an annual incidence of the primary outcome of 8% among patients assigned placebo, the study will have at least 80% power to detect a relative reduction of 15% in the incidence of the primary outcome among patients assigned B vitamins (to 6.8%/year), applying a two-tailed level of significance of 5%.

CONCLUSION

VITATOPS aims to recruit and follow-up 8000 patients between 1998 and 2008, and provide a reliable estimate of the safety and effectiveness of folic acid, vitamin B(12), and vitamin B(6) supplementation in reducing recurrent serious vascular events among a wide range of patients with TIA and stroke throughout the world.

Self-perceived memory impairment and cognitive performance in an elderly independent population with age-related white matter changes

OBJECTIVES

To determine whether self-perceived memory impairment is associated with the severity of white matter changes (WMC) and is related to cognitive impairment.

METHODS

Data were drawn from the multinational Leukoaraiosis and Disability Study (LADIS), which investigates the impact of WMC on global functioning. WMC severity was rated using the Fazekas scale. Medial temporal lobe atrophy (MTA) was scored visually and mean values were calculated. The neuropsychological battery consisted of the Mini-Mental State Examination, a modified version of the VADAS-Cog, Trail making and Stroop tests. A question about self-perceived memory impairment was used as a measure for presence of memory complaints. Cognitive performance was analysed test-by-test and in three main domains: memory, executive functions and speed/motor control. The Geriatric Depression Scale (GDS) was used as a measure of depressive symptoms.

RESULTS

Six hundred and thirty-eight subjects were included in this study. No association was found between memory complaints and the severity of WMC. Subjects with memory complaints (n = 399) had a higher GDS score [t((637)) = -7.15; p<0.02] and performed worse on almost all cognitive tests and on the three cognitive domains. Multiple linear regression showed that the worse performance on the memory domain was associated with memory complaints independently of depressive symptoms, WMC severity and MTA (R(2) = 0.183; F = 17.09, beta = -0.126; p<0.05).

CONCLUSION

In a sample of non-disabled elderly subjects with WMC, self-perceived memory impairment is significantly associated with objective memory impairment independently of the WMC severity, depressive symptoms and MTA.

A novel system for large-scale gene expression analysis: bacterial colonies array

In the present work, we report the use of bacterial colonies to optimize macroarray technique. The devised system is significantly cheaper than other methods available to detect large-scale differential gene expression. Recombinant Escherichia coli clones containing plasmid-encoded copies of 4,608 individual expressed sequence tag (ESTs) were robotically spotted onto nylon membranes that were incubated for 6 and 12 h to allow the bacteria to grow and, consequently, amplify the cloned ESTs. The membranes were then hybridized with a beta-lactamase gene specific probe from the recombinant plasmid and, subsequently, phosphorimaged to quantify the microbial cells. Variance analysis demonstrated that the spot hybridization signal intensity was similar for 3,954 ESTs (85.8%) after 6 h of bacterial growth. Membranes spotted with bacteria colonies grown for 12 h had 4,017 ESTs (87.2%) with comparable signal intensity but the signal to noise ratio was fivefold higher. Taken together, the results of this study indicate that it is possible to investigate large-scale gene expression using macroarrays based on bacterial colonies grown for 6 h onto membranes.

Improved accuracy of hysteroembryoscopic biopsies for karyotyping early missed abortions

OBJECTIVE

To assess the potential of direct embryo and chorion biopsies obtained by hysteroembryoscopy for karyotyping early missed abortions.

DESIGN

Clinical prospective descriptive study.

SETTING

Instituto Valenciano de Infertilidad, Valencia, Spain.

PATIENT(S)

Sixty-eight women (71 gestational sacs) with missed abortions. The gestational age on ultrasound was 6.3 weeks (range, 4-10 weeks).

INTERVENTION(S)

Transcervical hysteroembryoscopy before curettage.

MAIN OUTCOME MEASURE(S)

Comparison between the cytogenetic results from hysteroembryoscopic biospies and those of the curettage material.

RESULT(S)

Hysteroembryoscopic biopsies could be taken in 97.2% of the gestational sacs. Direct embryo and chorion biopsies were suitable for chromosomal analysis. Selective samples identified misdiagnoses of the conventional curettage karyotype due to maternal contaminating tissues in 22.2% of the cases. Direct hysteroembryoscopic biopsies also enabled the diagnosis of a true placental mosaicism and the study of the individual karyotype of each gestational sac in bizygotic twin missed abortions.

CONCLUSION(S)

In early missed abortions, karyotypes from direct hysteroembryoscopic biopsies were more accurate than those from the curettage material. The finding of a 46,XX karyotype in the curettage material is not a reliable result.

Brain metastases of a malignant fibrous histiocytoma presenting as an acute cerebral hemorrhage

Intracranial metastases from malignant fibrous histiocytoma (MFH) are rare, particularly with associated hemorrhage. This article reports one case and presents a review of the literature on this topic. A 55-year-old man presented with acute drowsiness, aphasia and right homonymous hemianopsia and hemiparesis. The first CT scan showed a left occipitoparietal hematoma and the second one, nodular, contrast-enhanced lesions. He had been previously operated on soft tissues MFH. Lung metastases developed subsequently. A craniotomy was performed with evacuation of the hematoma and total gross resection of the mass lesions. Microscopic examination disclosed a metastasis from a MFH. Neoangiogenesis, stimulated by angiogenic growth factors, seems to take part in this vascular, stroke-like event. Due to longer survivals of patients harboring systemic sarcomas, these tumors should be considered in the differential diagnosis of intracranial neoplasms, whether hemorrhagic or not. In particular, history of a previous soft tissue or heart tumor associated with lung metastasis should evoke the possibility of MFH metastasis.

Fine-needle aspiration diagnosis of Kaposi's sarcoma in a developing country

Fine-needle aspiration (FNA) cytology was performed on 15 patients with peripheral lymphadenopathy and/or skin lesions referred to the Department of Pathology of the Hospital Central of Maputo, Maputo, Mozambique. Epitrochlear lymph nodes were the most frequently aspirated site. All aspirates allowed diagnoses of Kaposi's sarcoma (KS). Smears contained loosely cohesive clusters of bland spindle cells, with a radial arrangement and nuclear crush artifacts. These diagnostic clues have not been described in other spindle-cell intranodal lesions that should be considered in differential diagnoses. Taking into consideration the high prevalence of AIDS and limited resources for diagnosis in Africa, FNA cytology appears to be a useful method for the diagnosis of KS in developing countries, reducing the necessity for surgical lymph node excision.

Study on COgnition and Prognosis in the Elderly (SCOPE): baseline characteristics

The Study on COgnition and Prognosis in the Elderly (SCOPE) is a multi-centre, prospective, randomized, double-blind, parallel-group study. The primary objective of SCOPE is to assess the effect of the angiotensin II type 1 (AT1) receptor blocker, candesartan cilexetil 8-16 mg once daily, on major cardiovascular events in elderly patients (70-89 years of age) with mild hypertension (DBP 90-99 and/or SBP 160-179 mmHg). The secondary objectives of the study are to test the hypothesis that antihypertensive therapy can prevent cognitive decline (as measured by the Mini Mental State Examination, MMSE) and dementia, and to assess the effect of therapy on total mortality, myocardial infarction (MI), stroke, renal function, and hospitalization. A total of 4964 patients from 15 participating countries were recruited during the randomization phase of SCOPE, exceeding the target population of 4000. The mean age of the patients at enrolment was 76 years, the ratio of male to female patients was approximately 1:2, and 52% of patients were already being treated with an antihypertensive agent at enrolment. The majority of patients (88%) were educated to at least primary school level. At randomization, mean sitting blood pressure values were SBP 166 mmHg and DBP 90 mmHg, and the mean MMSE score was 28. Previous cardiovascular disease in the study population included myocardial infarction (4%), stroke (4%) and atrial fibrillation (4%). Men, more often than women, had a history of previous MI, stroke and atrial fibrillation. A greater percentage of men were smokers (13% vs 6% in women) and had attended university (11% vs 3% of women). Of the randomized patients, 21% were 80 years of age. In this age group smoking was less common (4% vs 10% for 70-79-year-olds) and fewer had attended university (4% vs 7% for 70-79-year-olds). The incidence of MI was similar in both age groups. However, stroke and atrial fibrillation had occurred approximately twice as frequently in the older patients. The patients' mean age at baseline was similar in the participating countries, and most countries showed the approximate 1:2 ratio for male to female patients. There was also little inter-country variation in terms of mean SBP, DBP or MMSE score. However, there was considerable regional variation in the percentage of patients on therapy prior to enrolment.

Study on COgnition and Prognosis in the Elderly (SCOPE)

The Study on COgnition and Prognosis in the Elderly (SCOPE) is a multicentre, prospective, randomized, double-blind, parallel-group study designed to compare the effects of candesartan cilexetil and placebo in elderly patients with mild hypertension. The primary objective of the study is to assess the effect of candesartan cilexetil on major cardiovascular events. The secondary objectives of the study are to assess the effect of candesartan cilexetil on cognitive function and on total mortality, cardiovascular mortality, myocardial infarction, stroke, renal function, hospitalization, quality of life and health economics. Male and female patients aged between 70 and 89 years, with a sitting systolic blood pressure (SBP) of 160-179 mmHg and/or diastolic blood pressure (DBP) of 90-99 mmHg, and a Mini-Mental State Examination (MMSE) score of 24 or above, are eligible for the study. The overall target study population is 4000 patients, at least 1000 of whom are also to be assessed for quality of life and health economics data. After an open run-in period lasting 1-3 months, during which patients are assessed for eligibility and those who are already on antihypertensive therapy at enrolment are switched to hydrochlorothiazide 12.5 mg o.d., patients are randomized to receive either candesartan cilexetil 8 mg once daily (o.d.) or matching placebo o.d. At subsequent study visits, if SBP remains >160 mmHg, or has decreased by <10 mmHg since the randomization visit, or DBP is >85 mmHg, study treatment is doubled to candesartan cilexetil 16 mg o.d. or two placebo tablets o.d. Recruitment was completed in January 1999. At that time 4964 patients had been randomized. All randomized patients will be followed for an additional 2 years. If the event rate is lower than anticipated, the follow-up will be prolonged.

White matter changes in stroke patients. Relationship with stroke subtype and outcome

White matter changes (WMC), detected by imaging techniques, are frequent in stroke patients. The aim of the study was to determine how WMC relate to stroke subtypes and to stroke outcome. We made a systematic Medline search for articles appearing with two of the following key words: either 'WMC or white matter lesions or leukoencephalopathy or leukoaraiosis' and 'stroke or cerebral infarct or cerebral hemorrhage or cerebrovascular disease or transient ischemic attack (TIA)'. WMC, as defined radiologically, are present in up to 44% of patients with stroke or TIA and in 50% of patients with vascular dementia. WMC are more frequent in patients with lacunar infarcts, deep intracerebral hemorrhages, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy and cerebral amyloid angiopathy. After an acute ischemic stroke, WMC are associated with a higher risk of death or dependency, recurrent stroke of any type, cerebral bleeding under anticoagulation, myocardial infarction, and poststroke dementia. WMC in stroke patients are often associated with small-vessel disease and lead to a higher risk of death, and poor cardiac and neurological outcome. However, several questions remain open and need further investigations.

[Relationship between parenteral gangliosides administration and the Guillain-Barré syndrome]

OBJECTIVE

We carried out a case a case-control study to analyze the relationship between parenteral gangliosides administration and the Guillain-Barré syndrome.

PATIENTS AND METHODS

We retrieved 64 patients with the diagnosis of Guillain-Barré syndrome, and 148 controls. In cases and controls the proportion and 95% confidence intervals (CI) of subject receiving gangliosides, was calculated. The number of patients with the Guillain-Barré syndrome who needed ventilation or died was also calculated.

RESULTS

Four of 36 patients (95% CI = 81-0.6), over 40 years, received gangliosides prior to Guillain-Barré syndrome. One of these patients was ventilated (95% CI = 25-2) and died. None of the controls less than 40 years old took gangliosides, while from the 108 over 40 (95% CI = 15-4) 9 received gangliosides. None developed signs suggesting Guillain-Barré syndrome. Although gangliosides were more often used in Guillain-Barré syndrome (OR = 1.75), the difference was not significant (95% CI = 4.82-0.69).

CONCLUSION

The present work proves that in spite of the association of Guillain-Barré syndrome, with gangliosides intake, there is no statistical difference between this group of patients and control population.

Vascular risk factors for perimesencephalic nonaneurysmal subarachnoid hemorrhage

No data have been published on the role of vascular risk factors for perimesencephalic nonaneurysmal subarachnoid hemorrhage (PMSAH). In a case-control study we compared the prevalence of vascular risk factors in 40 consecutive patients who suffered a perimesencephalic subarachnoid hemorrhage with that in two controls groups: (a) 120 subjects registered with a general practitioner (GP: matched at a 3:1 ratio for age and sex) and (b) 81 proxies of patients of a hospital outpatient clinic. A conditional multivariate logistic regression model was performed taking into account the matched design. Hypertension was more frequent among PMSAH patients than among the two control group subjects for men and women. Among women, smoking was more common in PMSAH than in the GP control group. The conditional multivariate logistic regression model confirmed that hypertension was an independent risk factor for PMSAH (P = 0.036) Hypertension is a preventable risk factor of PMSAH.

Fully automated liquid culture system compared with Löwenstein-Jensen solid medium for rapid recovery of mycobacteria from clinical samples

The aim of this study was to compare the rate of recovery of mycobacteria and the time to detection in 5208 samples using the MB/BacT culture system (Organon Teknika, USA) and Löwenstein-Jensen medium. Mycobacteria were recovered from 301 (5.7%) samples. Two hundred fifty-seven (85.3%) isolates from 114 patients were Mycobacterium tuberculosis [135 (52.5%) smear-positive, 122 (47.4%) smear-negative], and 44 (14.6%) were potentially pathogenic environmental mycobacteria. The yield with the MB/BacT was higher than that with Löwenstein-Jensen [287 (95.3%) vs. 200 (66.4%), P<0.001] for both Mycobacterium tuberculosis [247 (96.1%) vs. 187 (72.7%), P<0.001] and potentially pathogenic environmental mycobacteria [40 (90.9%) vs. 13 (29.5%), P<0.001], mainly at the expense of the smear-negative samples. Moreover, 70 (27.2%) samples were positive only in the MB/BacT, whereas ten (3.8%) samples were positive only in Löwenstein-Jensen. The number of patients with tuberculosis detected by the MB/BacT was higher than that detected by Löwenstein-Jensen medium [111 (97.3%) vs. 89 (78%), P<0.001]. In 25 (21.9%) patients the diagnosis was established solely by means of the MB/BacT. In smear-positive and smear-negative samples, the mean times to detection of Mycobacterium tuberculosis were 16.7 and 26.3 days, respectively, with Löwenstein-Jensen and 11.5 and 19.3 days, respectively, with the MB/BacT. These results indicate that the MB/BacT is more efficient and faster than Löwenstein-Jensen for the recovery of mycobacteria.

Comparison of the ligase chain reaction with solid and liquid culture media for routine detection of Mycobacterium tuberculosis in nonrespiratory specimens

The aim of this study was to compare the results of a commercial assay based on the ligase chain reaction [(LCR) LCx Probe System MTB; Abbott, USA] with those of culture in liquid medium (Septi-Chek AFB; Becton-Dickinson, USA) and culture on the egg-based Löwenstein-Jensen solid medium for the direct detection of Mycobacterium tuberculosis complex in nonrespiratory specimens. The results were analyzed according to the standard definition of a true-positive result. Two hundred thirty-five nonrespiratory samples routinely submitted to rule out tuberculosis were analyzed. All samples were smear-negative. Mycobacterial growth in either culture medium was detected in 18 (7.6%) specimens: Mycobacterium tuberculosis was recovered from seven (38.9%) specimens cultured on Löwenstein-Jensen medium and from 18 (100%) specimens cultured in Septi-Chek AFB. The LCR protocol was positive in 22 specimens. None of the LCR-negative controls showed positive results. All samples positive by culture on Löwenstein-Jensen medium were positive by culture in liquid medium and by the LCR assay. However, Mycobacterium tuberculosis was detected by culture in liquid medium in two specimens that were negative by the LCR assay, whereas six specimens negative by culture in liquid medium were positive by the LCR protocol; three of these were identified as true-positive results of the LCR assay. The sensitivity, specificity, and positive and negative predictive values were 33.3%, 100%, 100%, and 93.8%, respectively, for Löwenstein-Jensen medium; 85.7%, 100%, 100%, and 98.6% for the liquid medium; and 90.4%, 98.5%, 86.3%, and 99% for the LCR assay. These findings indicate that the LCR assay may be a valid method of high diagnostic yield for direct detection of Mycobacterium tuberculosis complex in nonrespiratory specimens.

Comparison of MB-check and Löwenstein-Jensen media for recovery of mycobacteria

We have compared the rate of recovery of mycobacteria with the MB-Check culture system (liquid phase) and the Löwenstein-Jensen (LJ) medium in 2,907 clinical specimens obtained from 830 patients submitted for mycobacterial culture during 1-year period. Direct smear examination was carried out by auramine-rhodamine staining. All primary isolates from the culture media were confirmed by Ziehl-Neelsen staining and identified by acridinium-ester-labeled DNA probes specific for Mycobaterium tuberculosis complex. A total of 214 isolates were of the M. tuberculosis complex (88 patients) and 54 of "potentially pathogenic environmental mycobacteria" (45 patients). A total of 117 (54.7%) samples were smear-positive and the remaining 97 (45.3%) were smear-negative. There was a significant difference in the percentage of positive cultures obtained by the MB-Check method (99.1%) as compared with the LJ medium (73.8%) (P < 0.05). This difference, however, occurred almost exclusively at the expense of the 97 smear-negative samples (positive cultures 97.95% by the MB-Check method vs. 42.3% by the LJ culture, P < 0.05). The number of patients diagnosed of tuberculosis by the MB-Check was significantly higher as compared with LJ medium (88 [100%] vs. 77 [87.5%], P < 0.05). In 11 (12.5%) patients, the diagnosis was only established by the MB-Check system. In smear-positive samples, the mean (+/-SD) detection time for M. tuberculosis complex was 14.8 +/- 8 days with MB-Check and 19.9 +/- 7 days with LJ medium. The corresponding figures in smear-negative samples were 22.8 +/- 3 days and 27.8 +/- 6 days, respectively. DNA probes directly applied to MB-Check liquid medium showed a sensitivity of 98.8% and specificity of 100%. These results indicate that the MB-Check system is more efficient for the recovery of mycobacteria than LJ medium.

[The factors triggering epileptic crises according to patients]

The authors were interested in knowing what epileptic patients think about seizure-inducing factors; whether they are convinced that their seizures are induced by any trigger factor and, if so, which factor it is. While mainly interested in the psychological reality of patients, data about objective factors could emerge from this study. An inquiry was made among the 1005 patients who attended the outpatient clinic for epilepsy of Santa Maria Hospital, Lisbon, during five months of 1994. Of the 308 that answered the inquiry, 147 could not recognise any inducing factor for their last seizure, while 144 mentioned such a factor (of the latter, some mentioned two or more factors acting together). Emotional factors were most often mentioned. Seventeen answers were discarded. In many instances, seizure-inducing factors are identified by the patients but difficult to objectivize by investigators, namely those of emotional type. Answers given by the patients might help doctors to provide patients with better care.

Incidence of autoantibodies in the infertile population

The purpose of this study was to determine the incidence of autoantibodies in patients with no term pregnancies. Patients selected included 43 with primary infertility and 110 with a history of pregnancy loss. In the first group the incidence of antinuclear antibodies (ANA) and IgG and IgM antiphospholipid antibodies (APL) was 37.2% (p < 0.05) and 53.5% (p < 0.05), respectively. In the group of patients with a history of miscarriage, 31.8% (p < 0.05) were positive for ANA and 38.2% (p < 0.05) for APL. Controls were 35 healthy patients with proven fertility and no history of pregnancy loss or autoimmune disease. In this group the incidence of ANA was 5.7% and 11.4% for APL. The high incidence of autoantibodies found in patients with primary infertility might suggest a direct involvement of these antibodies in reproductive failure and consequently in IVF and assisted fertility procedures. The prevalence of ANA and APL has been extensively described in patients with a history of recurrent pregnancy losses (RPL). In this study we observed antibodies even after the first miscarriage. We therefore conclude that patients with a history of reproductive failure should be immunologically evaluated and treated before undergoing assisted fertilization techniques or before a new pregnancy in those cases of RPL.

Angiogenesis in breast cancer is related to age but not to other prognostic parameters

Angiogenesis is essential for tumour growth and metastasis. In spite of its relevant biological significance, recent studies have produced conflicting results regarding the capacity of microvessel quantifications in breast carcinomas to predict patients' outcome and the existence of metastasis. In order to provide further information in this issue, we evaluated tumour angiogenesis in a series of 45 primary breast carcinomas (mean age: 55.3 +/- 14.2) and examined their association with established or potentially useful prognostic parameters. Microvessels were highlighted by immunohistochemical staining for factor VIII-related antigen and counted in the three most vascularized areas in a 200 x field (0.74 mm2) by four observers simultaneously. Results were analysed for the average vessel count of each case. The mean intratumoural microvessel count was 57.7 +/- 24.4 (range: 24.3 to 127.7). We found a statistically significant association between angiogenesis and age. The microvessels count in patients younger than 50 years was 67.8 +/- 26.4, from 51 to 70 years, 52.0 +/- 22.8 and over 71 years, 46.1 +/- 14.2 (p = 0.03). Node positive patients had slightly higher microvessel counts (60.3 +/- 25.3) than node negative ones (54.4 +/- 23.5); this difference was not significant (p = 0.42), even when we considered each age group per se. No association was found between angiogenesis and tumour size, histologic grade, estrogen receptor, MIB-1 index, ploidy and expression of p53 and c-erbB-2. Our results suggest that invasive breast carcinoma-induced angiogenesis is age-dependent.

Relation between curricular activities and problem behaviors of students with mental retardation

The correlations between students' problem and appropriate behaviors and characteristics of the curricular activities in which they were engaged was examined. Curricular activities were rated to determine whether they were socially functional, peer-referenced, and behaviorally functional. Students' behaviors and curricular activities in 64 classrooms were directly observed during the regular daily routine. Results showed a significant negative correlation between ratings of the characteristics of curricular activities and students' problem behaviors and a significant positive correlation between ratings of curricular activities and students' appropriate behaviors. The pattern of significant correlations was also reflected in individual subscale scores. Implications of these results for classroom practice and the remediation of problem behaviors were discussed.

[Acute cerebrovascular disorder and arterial hypertension. Prospective study with 248 patients]

OBJECTIVE

To evaluate the hypertension associated to different types and sub-types of cerebrovascular disease (stroke), with particular reference to the frequency of hypertension, the values of blood pressure, the risk factors and the involvement of other target organs.

DEFINITION

Prospective study in 248 patients with acute stroke admitted to a Clinical Medicine Unit in three independent time periods.

SETTING

Internal Medicine Clinic of University Hospital in Lisbon.

METHODS

Medical, neurological and cardiologic examination were performed and all patients were also submitted to different complementary tests, including a computer tomography scan of the brain, and an echocardiogram. The values of blood pressure were measured in the admission at the urgent service and 24 h after in the the ward. We identified three sub-types of stroke: intracerebral hemorrhage (IH), ischaemic stroke (IS) and lacunes (L). For each sub-type and for those with hypertension or not, we evaluated: age, sex, duration of stay in hospital and mortality. We also compared for each sub-type the values of blood pressure, the risk factor and the repercussion on other target organs.

PATIENTS

Two hundred and forty eight patients (52% were men) with mean age 68.0 +/- 10.2 years, and ages among 40 and 92 years. Thirty-seven patients (15%) died.

MAIN RESULTS

In the entire population (n = 248) hypertension were more prevalent in IH 83% and L 82% than in IS 59% (p < 0.0005). Hypertension was present in 172 patients (69%) and 81 (47%) were IS, 58 (34%) L and 33 (19%) IH. Sixty six percent of the 172 patients with hypertension had at least another risk factor and the most aged ones (> 65 years old) were more frequent in IS 75% than in HI 45% or L 58% (p < 0.001). For all subtypes blood pressure measurements were higher in admission than in ward and they were also higher in IH than in IS (p < 0.05). Hypertensive cardiopathy was more prevalent in IH 76% and L 61% than in IS 49% (p < 0.05). Renal failure was more frequent in IS 37% than in IH 28% and L 17% (p < 0.05).

CONCLUSIONS

Hypertension is very frequent, and like advanced age is a major risk factor of stroke. Hypertension is frequently associated with one or more risk factors. Hypertensive cardiopathy is more related with IH and L and the renal involvement with IS.

Comparison of solid and liquid culture media with polymerase chain reaction for detection of Mycobacterium tuberculosis in clinical samples

The aim of this study was to determine the sensitivity of different methods--two commercial polymerase chain reaction (PCR) kits (a protocol of nested PCR and a protocol of amplification of the IS6110 insertion element), the radiometric Bactec system, the Septi-Chek AFB culture system, and culture in Löwenstein-Jensen (LJ) solid medium--for the detection of Mycobacterium tuberculosis. One hundred clinical samples from 51 patients with culture-positive tuberculosis (81 specimens) and 19 controls (19 specimens) were used. Eighty-nine percent of the samples were smear negative. In the 81 specimens obtained from patients with tuberculosis, the frequency of positivity was 66.6% for nested PCR, 63% for culture in liquid media, 38.3% for IS6110 assay, and 28.4% for culture in LJ medium. In 18 samples obtained by invasive procedures in patients with tuberculosis, mycobacterial DNA was detected by nested PCR in 83.3% (including all samples positive by culture on liquid media), by culture in liquid media in 77.7% by culture on LJ medium in 27.7%, and by the IS6110 assay in 11.1%. No false-positive results were obtained from the negative control specimens with any of the techniques tested. The sensitivity of the reamplification protocol appears to be superior to that of the IS6110 assay and similar to that of the Bactec system.

Incidence and risk factors of ischaemic and haemorrhagic stroke in Europe. EUROSTROKE: A collaborative study among research centres in Europe: rationale and design

EUROSTROKE is a collaborative study among ten European research centres to investigate (1) the variation in incidence of fatal and non-fatal ischaemic and haemorrhagic stroke among populations in different European countries; (2) whether the observed differences in stroke incidence across countries can be explained by differences in prevalence of established cardiovascular risk factors; (3) the relative importance of selected dietary factors (potassium intake, smoking, alcohol consumption), haemostatic disturbances (fibrinogen) and co-morbidity (rheumatic heart disease, atrial fibrillation) compared to established risk factors as determinants of the occurrence of ischaemic and haemorrhagic stroke. The EUROSTROKE database is drawn from ten European population-based prospective follow-up studies (cohorts) and is designed as a case-control study nested within these ten ongoing studies.

[Acute cerebrovascular accident and heart disease. Prospective study of 248 patients]

OBJECTIVE

To evaluate the heart disease associated to different type and sub-types of cerebrovascular disease with particular reference to potential cardiac sources of embolus (CPE).

DESIGN

Prospective study in 248 consecutive patients with acute stroke, admitted to a Clinical Medicine Unit in three independent time periods.

SETTING

Internal Medicine Clinic of University Hospital in Lisbon.

METHODS

Neurologic and cardiologic examination were performed and all patients were also submitted to different complementary tests, including a Computer Tomography Scan of the brain (TAC) and a Echocardiogram (ECO). We identified two types and two sub-types: intracerebral haemorrhage (HI) or ischemic stroke (AI) and among AI, cortical (C) or subcortical (SC) ischemic stroke. For each type and sub-type we evaluated past history, heart disease, hypertension (HTA), electrocardiogram, echocardiogram (ECO) and CPE.

PATIENTS

Two hundred and forty eight patients (52% were men) with mean age 68.0 +/- 10.2 years and ages between 40 and 92 years. Thirty seven (15%) died.

MAIN RESULTS

Eighty four percent were AI and among them 45% were C. Previous strokes were more prevalent in AI 29% (p < 0.01). There was heart disease in 81% and hypertensive cardiopathy was more frequent in HI 63% (p < 0.002). HTA and atrial fibrillation (FA) were more frequent in HI 83% (p < 0.05) and in AI 25% (p < 0.004) respectively. ECO showed a dilatation of left atrium more frequent in AI 28% (p < 0.05) and left ventricular concentric hypertrophy index (IHCE) in HI 50% (p < 0.05). CPE, including FA, was identified in 34% of patients, was more prevalent in AI 38% (p < 0.001) and among it FA was significantly more frequent in C 32% (p < 0.02).

CONCLUSIONS

Heart disease is very frequent in stroke. The diagnosis of this condition is very important for stroke prophylaxis and prognosis. HTA and hypertensive cardiopathy have a great prevalence and were more related to HI. CPE and FA were very frequent and their diagnosis are important for prevention of AI and specially for embolic stroke. ECO is useful to identify CPE in elderly patient in particular to characterize heart disease.

[Microangiopathic hemolytic anemia associated with neoplasms: an analysis of 5 cases and a review of the literature]

From January of 1990 to June of 1993 a diagnosis of microangiopathic hemolytic anemia (MHA) was made in 5 out off 121 new patients with malignant tumor. There were 3 females and 2 males, with a mean age of 57 yr (range: 43-75), and a primary tumor in stomach (n = 2), pancreas (n = 1) and of unknown origin (n = 2). In all cases histologic type was adenocarcinoma and diagnosis was obtained by marrow examination. Four patients developed a disseminated intravascular coagulation syndrome. Intravascular deposits of fibrin, intimal proliferation and tumoral microembolisms were noted in 2 cases. Patients did not received chemotherapy, and the median survival was 7 days (range: 3-61).