The impact of gender on the self-confidence of practical and surgical skills among OBGYN residents: a trinational survey

INTRODUCTION

Gender disparities exist in the OBGYN discipline. This study investigates, for the first time, whether gender impacts on the confidence of practical and surgical skills among OBGYN residents, and of being prepared to work as a specialist.

METHODS

The gynecological societies of Austria, Germany, and Switzerland established a web-based survey of 30 questions that was sent to all registered OBGYN members-in-training from August to September 2020. Data collection, controlling and analysis were performed by the Swiss Federal Institute of Technology in Zurich (ETH).

RESULTS

A total of 422 participants took part in the survey, of which 375 (88.9%) were female, 46 (10.9%) were male, and one (0.2%) was divers. The diverse participant was excluded from further analyses. The gender distribution was comparable in all three countries. Multiple regression analyses showed that gender is an independent variable significantly impacting on the confidence levels in performing standard gynaecological (p = 0.03) and obstetric (p < 0.001) procedures. Similarly, the feeling of confidence in being prepared for working as a specialist in a clinic showed to be gender-dependent (p < 0.001), however, not the feeling of being prepared for working as specialist in an outpatient setting (p = 0.37). The "female factor" significantly decreases the confidence rating for surgical and practical skills and for working in a hospital. Covariates including year of training, country, workload, receiving regular feedback, and implemented simulation training were included in all analyses.

DISCUSSION

Improvements of residency programs to promote female doctors to overcome factors reducing their confidence in their own OBGYN skills are highly warranted.

Postgraduate medical education in obstetrics and gynaecology: Where are we now and what do we need for the future? A study on postgraduate training in obstetrics and gynaecology in Germany, Austria and Switzerland

Objective: In this study, we aim to assess the current situation of postgraduate medical education in obstetrics and gynaecology in Germany, Austria and Switzerland. In addition, we aim to determine transferable advantages amongst the countries. Study design: We performed a survey through a digital questionnaire with a total of 40 questions. The survey was advertised via communication channels of the German, Austrian and Swiss gynaecological societies; the participants were enrolled anonymously. Results: A total of 422 trainees took part in the survey. Differences within the three countries where found regarding the workload and the training of sub-specialties. Generally, the participants described to spend the majority of their daily working hours on documentation. Concerning assessment of current training regulations, more than half of trainees stated that they were actually faced with notable difficulties to fulfil the required obligatory numbers of self-performed interventions being documented. When asked for their intrinsic feeling of safety, around two-third of trainees felt "confident to very confident" during standard interventions. These numbers were up to 12% higher in the group of trainees who experienced simulation training during their education. Conclusion: With the help of this survey, weak points can be identified such as workload and implementation of current training regulations. Projects and ideas as EBCOG PACT, EPAs, the reduction of bureaucracy through digitization and deepening skills through simulation make a valuable contribution to compensate for these deficits and to adapt to future requirements.

POS0956 MEDITERRANEAN DIET IN AXIAL SPONDYLOARTHRITIS: A NUTRITIONAL INTERVENTION STUDY

Background:

Mediterranean diet (MD) proved to be beneficial on disease activity in patients affected by rheumatoid arthritis. A few data are available in other rheumatic conditions.

Objectives:

A prospective monocentric study was conducted to evaluate the effect of a nutritional intervention based on the MD and to investigate the impact of such modification on disease activity of axial spondyloarthitis (ax-SpA).

Methods:

Patients affected by ax-SpA randomized to a nutritional intervention arm (N) or a control arm (C) and were assessed at baseline (T0) and at month 6 (T6). Patients in N underwent a nutritional evaluation and received suggestions for dietary modification at T0, and then every 2 months. Adherence to the MD was evaluated with the PREDIMED questionnaire (range 0-10) [1]. A multivariable regression analysis was conducted to identify independent predictors of PREDIMED and of ASDAS-CRP improvement at T6.

Results:

Eligible patients (161) were randomized to either N (81) or C (80); 47 in N and 63 in C completed the study. No relevant change of anthropometric or laboratory measures was observed at T6 in either group. A ≥20%PREDIMED improvement was more frequent in N (22/47, 46.8%) compared to C (13/63, 20.6%) (p<0.01). Also, a ≥20%ASDAS-CRP improvement was more frequent in N (8/47, 57.1%) compared to C (39/63, 40.6%) (p=0.020); and especially in those who achieved a ≥20%PREDIMED improvement (12/35, 34.3%) vs those who did not (2/73, 2.7%) (p<0.01). The nutritional intervention, a higher age, and a lower BMI increased the odds of achieving a ≥20%PREDIMED improvement; the ≥20%PREDIMED improvement was associated higher odds of achieving a ≥20%ASDAS-CRP improvement; psoriasis was negatively associated to the ASDAS-CRP improvement (Figure 1).

Conclusion:

A nutritional intervention is effective in improving adherence to the MD in ax-SpA. A higher adherence to the MD may have a beneficial impact on activity of ax-SpA. Patients with psoriasis may have a limited benefit from the dietary improvement.

References:

[1]Martínez-González, M.A. et al. A 14-item mediterranean diet assessment tool and obesity indexes among high-risk subjects: The PREDIMED trial.PLoS One2012,7.

Table 1.

Characteristics of the patients.

All patientsNutritionControlsAll patientsNutritionControlsBaselineMonth 6Females, n, (%)40 (36.4)18 (38.3)22 (34.9)Age, years, mean±SD51.7±1.353.0±1.349.6±1.3HLA-B27 positivity, n (%)58 (52.7)22 (46.8)37 (57.1)Psoriasis, n (%)58 (50.7)26 (55.3)32 (50.8)Disease duration (years), mean±SD15.3±9.715.7±1015±9.5Duration of b/tsDMARD treatment overall, years, mean±SD5±4.15.8±4.54.5±3.8NSAID, n (%)76 (69.1)30 (63.8)46 (73)csDMARD, n (%)14 (12.7)5 (10.6)9 (14.3)BMI, Kg/meters2, mean±SD26.5±5.426.5±4.326.6±6.126.4±5.326.3±426.6±6.1ASDAS-CRP, mean±SD2.1±12.1±0.92.1±12±1.11.8±0.92.1±1.2BASDAI, mean±SD37.6±2337.4±23.237.7±22.939.3±24.137.3±23.641.2±24.6BASFI, mean±SD20.5±21.421.6±19.219.7±2319.8±19.619.1±18.820.5±20.4BASMI, mean±SD1.6±21.9±2.21.4±1.71.8±2.11.9±2.41.7±1.9Tender joint count, mean±SD1.1±2.30.8±2.11.4±2.50.9±20.8±20.9±1.9Swollen joint count, mean±SD0.3±1.30.4±20.1±0.50.2±1.30.3±1.80.2±0.8Leeds Enthesitis Index, mean±SD0.2±0.80.3±10.2±0.61.1±21.3±2.21±1.8CRP, mg/L, mean ±SD3.4±6.23.2±3.93.7±7.43.5±5.62.6±3.14.1±6.9LDL-c, mg/dl, mean ±SD130.8±36.5132.3±35129.7±38.4130.6±34.7125.7±34.8134.4±34.5PREDIMED score, mean ±SD6.7±1.87±2.16.6±1.67.6±2.18.6±1.96.8±2

b/tsDMARD biological/targeted synthetic DMARDs; csDMARD conventional DMARDs. PREDIMED questionnaire to assess adherence to the Mediterranean diet.

Disclosure of Interests:

None declared.

Effect of an oral preparation containing hyaluronic acid, chondroitin sulfate, hydrolyzed collagen type II and hydrolyzed keratin on synovial fluid features and clinical indices in knee osteoarthritis. A pilot study

The aim of this study was to evaluate the effect of an oral preparation containing a naturally occurring matrix of hydrolyzed collagen type II, chondroitin sulfate (CS), and hyaluronic acid (HA), and bioactive oligopeptides of natural hydrolyzed keratin (K) in patients affected by knee OA through the evaluation of synovial fluid (SF) and clinical changes before and after treatment. Thirty patients with knee OA and swollen joint were included in the study and submitted to arthrocentesis. Patients were randomized in two groups: 1) the treatment group (N.15) took a dietary supplement containing 120 mg HA, 240 mg CS and 300 mg K once a day for 4 weeks; 2) the control group (N.15) was only submitted to arthrocentesis. Patient symptoms were evaluated at the beginning and at the end of the study by the WOMAC self-assessment questionnaire, the Lequesne algofunctional index, and the VAS forms. SF changes were evaluated by measuring local inflammatory indices, cytokines IL-1β, IL-8, IL-6, IL-10 and GM-CSF. The group of patients treated with the oral supplement showed an improvement in the clinical indices WOMAC (p<0.01), Lequesne (p=0.014) and VAS pain (p<0.01). On the contrary, no significant changes were found in the control group. The SF collected from the treated group showed a reduction of IL-8 (p=0.015), IL-6 and IL-10 levels, while no changes in cytokines were observed in the control group. This pilot study suggests that an oral administration of a preparation containing a combination of HA, CS and K can improve some clinical parameters and affect cytokine concentrations in SF in patients with knee OA.

Cultures of a human synovial cell line to evaluate platelet-rich plasma and hyaluronic acid effects

Synovial inflammation plays an important role in osteoarthritis (OA) pathogenesis. Different biological compounds have been tested mainly on chondrocytes, to treat early stages of OA. However, because OA has been recently defined as "an organ" pathology, investigation on synoviocytes is also needed. Therefore, the aim of the present study was to validate a human fibroblast-like synoviocytes cell line (K4IM) to test the effects of platelet-rich plasma (PRP) and hyaluronan (HA) on anabolic and catabolic gene expression and on HA secretion from cell cultures. In order to determine the effect of PRP and HA, K4IM cells were maintained in culture with or without TNF-α stimulation. In the presence of PRP, unstimulated K4IM cells presented the same expression of IL1B, IL6, CXCL8, VEGF, TIMP1, and hyaluronic synthase isoform HAS3 as primary human synoviocytes, while HA addition did not change their expression pattern, which was similar to control cells. Stimulated cells expressed significantly higher values of IL1B, CXCL8, and VEGF compared with unstimulated ones. PRP did not show any modification, except for VEGF, while HA addition modulated IL1B expression. PRP did not modulate HA release of both stimulated and unstimulated cells. Our study showed the possibility to use K4IM synoviocytes as an in vitro model to test biological compounds useful for the treatment of early OA. Primary cells reflect the phenotype of cells in vivo, but limited recovery from biopsies and restricted lifespan makes experimental manipulation challenging. Therefore, despite cell lines present some limitations, they could be used as an alternative for preliminary experiments.

Inflammation and oxidative stress in heart failure: effects of exercise intensity and duration

Although acute exercise is apparently pro-inflammatory and increases oxidative stress, it can promote the necessary stress stimulus to train chronic adaptations in patients with chronic heart failure (CHF). This study aimed to compare the effects of exercise intensity and duration on the inflammatory markers soluble tumor necrosis factor receptor (sTNFR1) and interleukin-6 (IL-6), and on oxidative stress [malondialdehyde (MDA) and antioxidant enzymes: catalase (CAT) and superoxide dismutase (SOD)] in individuals with CHF. Eighteen patients performed three exercise sessions: 30 min of moderate-intensity (M30) exercise, 30 min of low-intensity (L30) exercise, and 45 min of low-intensity (L45) exercise. Blood analysis was performed before exercise (baseline), immediately after each session (after), and 1 h after the end of each session (1h after). Thirty min of M30 exercise promoted a larger stressor stimulus, both pro-inflammatory and pro-oxidative, than that promoted by exercises L30 and L45. This was evidenced by increased sTNFR1 and MDA levels after exercise M30. In response to this stressor stimulus, 1 h after exercise, there was an increase in IL-6 and CAT levels, and a return of sTNFR1 to baseline levels. These findings suggest that compared with the duration of exercise, the exercise intensity was an important factor of physiologic adjustments.

Biomarkers, imaging and disease activity indices in patients with early axial spondyloarthritis: the Italian arm of the SpondyloArthritis-Caught-Early (SPACE) Study

The study aimed to evaluate biomarkers facilitating early diagnosis of axial spondyloarthritis (axSpA) and correlations between them and disease activity parameters and imaging indexes. Patients with low back pain (LBP) (≥3 months, ≤2 years, onset ≤45 years) participating in the Italian arm of the SpondyloArthritis-Caught-Early SPACE study underwent a physical examination, questionnaires, laboratory tests, X-rays and MRI of the spine and sacroiliac joints (SIJ). An expert rheumatologist formulated axSpA diagnosis in accordance with Assessment of SpondyloArthritis International Society (ASAS) criteria. Disease activity and physical functioning were assessed using imaging, clinical and serological indices. Spine and SIJ MRI and X-rays were scored independently by 2 readers using the SPARCC, mSASSS and NY-criteria. Patients were classified as: subjects with signs of radiographic sacroiliitis (r-axSpA), subjects with signs of sacroiliitis on SIJ-MRI but not on X-rays (nr-axSpA MRI SIJ+) or subjects with no signs of sacroiliitis on MRI/X-rays but with >2 SpA features and signs of bone oedema on MRI spine (nr-axSpA MRI SIJ-/undifferentiated SpA). Significant differences were found in the prevalence of radiographic sacroiliitis, active sacroiliitis on MRI and SPARCC SIJ scores. Biomarker levels were not significantly increased in any of the patient groups. The correlations between IL-17 and IL-23 and other indices were not significant; correlations were found between IL-22 and BASFI, BASG1, HAQ, VAS pain, between mSASSS and MMP3, and between the latter and hsCRP. Although not significantly higher in any of the three groups, IL-22, MMP3 and hsCRP values were correlated with some disease activity indexes and with mSASSS. Large observational studies are required to confirm these preliminary findings.

Italian Society for Rheumatology recommendations for the management of hand osteoarthritis

Hand osteoarthritis (OA) is a common and potentially disabling disease, with different features from hip and knee OA so that a specific therapeutic approach is required. Evidence based recommendations for the management of hand OA were developed by the European League Against Rheumatism (EULAR) in 2006. The Italian Society for Rheumatology (SIR) aimed to update, adapt to national contest and disseminate the EULAR recommendations for the management of hand OA. The multidisciplinary group of experts included specialists involved in the management of patients with hand OA. In order to maintain consistency with EULAR recommendations, a similar methodology was utilized by the Italian group. The original propositions were reformulated in terms of a search query and for every recommendation a systematic search was conducted updating EULAR recommendations' review. The propositions were translated in Italian and reformulated basing on collected evidences and expert opinion. The strength of recommendation was measured for each proposition with the EULAR ordinal and visual analogue scales. The original 11 propositions of EULAR recommendations were translated and adapted to Italian context. Further evidences were collected about non-pharmacological therapies, local treatments, intra-articular injection with SYSADOA and corticosteroids, and surgery. The SIR has developed updated recommendations for the management of hand OA adapted to the Italian healthcare system. Their implementation in clinical practice is expected to improve the management of patients with hand OA.

Italian Society of Rheumatology recommendations for the management of gout

OBJECTIVE

Gout is the most common arthritis in adults. Despite the availability of valid therapeutic options, the management of patients with gout is still suboptimal. The Italian Society of Rheumatology (SIR) aimed to update, adapt to national contest and disseminate the 2006 EULAR recommendations for the management of gout.

METHODS

The multidisciplinary group of experts included rheumatologists, general practitioners, internists, geriatricians, nephrologists, cardiologists and evidence-based medicine experts. To maintain consistency with EULAR recommendations, a similar methodology was utilized by the Italian group. The original propositions were translated in Italian and priority research queries were identified through a Delphi consensus approach. A systematic search was conducted for selected queries. Efficacy and safety data on drugs reported in RCTs were combined in a meta-analysis where feasible. The strength of recommendation was measured by utilising the EULAR ordinal and visual analogue scales.

RESULTS

The original 12 propositions were translated and adapted to Italian context. Further evidences were collected about the role of diet in the non-pharmacological treatment of gout and the efficacy of oral corticosteroids and low-dose colchicine in the management of acute attacks. Statements concerning uricosuric treatments were withdrawn and replaced with a proposition focused on a new urate lowering agent, febuxostat. A research agenda was developed to identify topics still not adequately investigated concerning the management of gout.

CONCLUSIONS

The SIR has developed updated recommendations for the management of gout adapted to the Italian healthcare system. Their implementation in clinical practice is expected to improve the management of patients with gout.

Inactivation of animal and human prions by hydrogen peroxide gas plasma sterilization

Prions cause various transmissible spongiform encephalopathies. They are highly resistant to the chemical and physical decontamination and sterilization procedures routinely used in healthcare facilities. The decontamination procedures recommended for the inactivation of prions are often incompatible with the materials used in medical devices. In this study, we evaluated the use of low-temperature hydrogen peroxide gas plasma sterilization systems and other instrument-processing procedures for inactivating human and animal prions. We provide new data concerning the efficacy of hydrogen peroxide against prions from in vitro or in vivo tests, focusing on the following: the efficiency of hydrogen peroxide sterilization and possible interactions with enzymatic or alkaline detergents, differences in the efficiency of this treatment against different prion strains, and the influence of contaminating lipids. We found that gaseous hydrogen peroxide decreased the infectivity of prions and/or the level of the protease-resistant form of the prion protein on different surface materials. However, the efficiency of this treatment depended strongly on the concentration of hydrogen peroxide and the delivery system used in medical devices, because these effects were more pronounced for the new generation of Sterrad technology. The Sterrad NX sterilizer is 100% efficient (0% transmission and no protease-resistant form of the prion protein signal detected on the surface of the material for the mouse-adapted bovine spongiform encephalopathy 6PB1 strain and a variant Creutzfeldt-Jakob disease strain). Thus, gaseous or vaporized hydrogen peroxide efficiently inactivates prions on the surfaces of medical devices.

On the mechanism of action of muscle fibre activity in synapse competition and elimination at the mammalian neuromuscular junction

Activity-dependent competition plays a crucial role in the refinement of synaptic connections in the peripheral and central nervous system. The reduction in number of axons innervating each neuromuscular junction during development, i.e. synapse elimination, appears to be one such competitive activity-driven event. Recently, we showed that asynchronous firing of competing presynaptic terminals is a key player in synapse elimination. Although some previous studies suggested that activity of the postsynaptic cell may be an intermediary in the disposal of redundant presynaptic inputs, the mechanism involved remains unknown. In the present study, in order to assess the role of evoked muscle activity in this process, we inhibited the generation of postsynaptic action potentials in muscle fibers in vivo, through the overexpression of inwardly rectifying Kir2.1 and Kir2.2 channels, via electroporation of the soleus muscle in the mouse hindlimb. Electrophysiological and morphological data show that overexpression of potassium channels in the endplate region of neonatal muscle fibres induces membrane hyperpolarization and an increase in conductance, inhibition of the action potential mechanism and prolonged persistence of polyneuronal innervation. These changes are not seen in muscle fibres with overexpression of a non-conducting Kir2.1 mutant. Our results are compatible with the interpretation that the block of action potential generation, even in single endplates, can inhibit synapse elimination through local signalling.

[Septic arthritis: a 12 years retrospective study in a rheumatological university clinic]

BACKGROUND

Septic arthritis is a disabling and potentially life-threatening condition that requires prompt diagnosis and treatment. The most important risk factors are joint prosthesis, pre-existing joint disease and immunosuppressive drugs. The aim of our study therefore was to revaluate all septic arthritis cases discharged from our Rheumatologic Unit in the last 12 years, to assess the risk factors, the clinical and laboratory characteristics, the causative microorganisms and its possible increase in frequency.

METHODS

The medical records of 42 consecutive patients with septic arthritis discharged from our Rheumatology Unit between January 1995 and December 2006 were reviewed. The patients ranged in age from 23 to 90 and there isn't gender predominance. Septic arthritis was diagnosed based on the finding of purulent material in the joint space and/or the isolation of a bacterial pathogen from joint fluid. Demographic data, risk factors, co-morbidity, clinical manifestations, time interval between symptoms onset and diagnosis, treatment and laboratory data including serum white blood cell count, erythrocyte sedimentation rate (ESR), C reactive protein (CRP), synovial white blood cells and culture results were analysed. We considered these parameters in the whole population and in two different age groups (< or =60, >60) and tried to determine if there was a change of microorganisms involved in septic arthritis during the years.

RESULTS

Of 42 patients, 47% were aged 60 and younger. Only 10 patients were admitted to our unit before 2001. A predisposing factor was recorded in 90,5% of cases: 15 patients had rheumatoid arthritis, 8 were diabetic, 6 had seronegative arthritis, 4 had a connective tissue disease, 8 patients had a prosthetic infection and 3 were subjected recently to arthrocentesis. We found that patients aged 60 and younger were more frequently affected by joint disease and had a synovial white blood cell count lower than patients older than 60. Staphylococcus aureus caused septic arthritis in 70% of cases before 2001, and only in 35,8 % after 2001. Also, after 2001, some infections were caused by more unusual pathogens, prevalently in patients treated with TNFa inhibitors. Instead Streptococcus infections were found only in patients aged 70 and older.

CONCLUSION

The incidence of bacterial arthritis has increased in the last six years and there was a modification of microorganisms involved, possibly related to a greater therapeutic aggressiveness. The increased frequency of joint disease and the use of immunosuppressive drugs in patients under the age of 60 could be responsible for a lower synovial white blood cell count in these patients.

[Septic arthritis: what is the role for the rheumatologist?]

Septic arthritis (SA) is a clinical emergency with considerable morbidity and mortality that can lead to rapid joint destruction and irreversible loss of function. The reported incidence varies from 2-5 cases per 100.000 individuals per year in the general populations to 70 cases per 100.000 individuals annually among patients with rheumatoid arthritis (RA). Predisposing factors are immunosuppressive and corticosteroids therapy and RA "itself". The expected decrease in incidence of SA was not seen over the last 20 years period but we can, on the contrary, expect an increase in the frequency of its appearance because of the population ageing, the increasingly prosthetic joint replacement, the ability of the bacteria to evade clearance by the host immune response and the rapidly growing number of patients with RA, ankylosing spondylitis and psoriatic arthritis treated with tumour necrosis factor alpha (TNF alpha) antagonists. Up to now there have been conflicting reports regarding joint infections in patients under anti-TNF therapy but according to data from Deutsch as well as the British register there might be an increase in the incidence of joint infections in anti-TNF treated patients. Microscopic analysis and culture of synovial fluid are fundamental diagnostic tools in the evaluation of possible joint sepsis. Sonographic guidance of arthrocentesis led to successful aspiration of difficult-to-access joints as shoulder and hip. There is controversy over which mode of drainage of septic synovial fluid should be employed but needle aspiration appear to be preferable to surgical treatment as an initial mode of treatment of SA. Rheumatologists should have a central role in the diagnosis and management of SA.

Rheumatoid arthritis is the major risk factor for septic arthritis in rheumatological settings

Septic arthritis (SA) is a clinical emergency with considerable morbidity and mortality that can lead to rapid joint destruction and irreversible functional loss. The reported incidence varies from 2-5 cases/100,000 person-years in the general population to 70 cases/100,000 person-years among patients with rheumatoid arthritis. In fact, individuals with rheumatoid arthritis are at particular risk for developing SA. This may be due to several reasons: joint disease predisposes to bacterial joint colonization and RA itself and its treatment with corticosteroids, disease-modifying antirheumatic drugs (DMARDs) and biological therapies may decrease the immune function required for protection from pathogens. Steroids and DMARDs seem to affect the leukocyte synovial count; indeed, RA patients with SA have a leukocyte count in synovial fluid (SF) lower than patients with SA without underlying rheumatic diseases. The diagnosis of SA in RA patients can be difficult because the development of a hot painful joint is often confused with a relapse of the underlying joint disease leading to delay in diagnosis. For this reason the microscopic analysis and culture of synovial fluid are crucial to exclude septic arthritis.

Wegener's granulomatosis confined to nervous system

Wegener's granulomatosis (WG) is a multisystemic necrotising granulomatous vasculitis of small and medium sized vessels, that primarily involves the upper and lower respiratory tracts, lung tissues and kidneys. Serum antineutrophil cytoplasmic antibodies (ANCA) are a sensitive and specific marker of WG. Whereas the peripheral nervous system is often involved in WG, central nervous system manifestations are reported only in 2-8%, and are rarely present at onset. We report on a patient with atypical neurological presentation of ANCA negative WG in whom the diagnosis was made only after a meningeal biopsy.

Non-malignant consequences of decreasing asbestos exposure in the Brazil chrysotile mines and mills

AIMS

To investigate the consequences of improvement in the workplace environment over six decades (1940-96) in asbestos miners and millers from a developing country (Brazil).

METHODS

A total of 3634 Brazilian workers with at least one year of exposure completed a respiratory symptoms questionnaire, chest radiography, and a spirometric evaluation. The study population was separated into three groups whose working conditions improved over time: group I (1940-66, n = 180), group II (1967-76, n = 1317), and group III (1977-96, n = 2137).

RESULTS

Respiratory symptoms were significantly related to spirometric abnormalities, smoking, and latency time. Breathlessness, in particular, was also associated with age, pleural abnormality and increased cumulative exposure to asbestos fibres. The odds ratios (OR) for parenchymal and/or non-malignant pleural disease were significantly lower in groups II and III compared to group I subjects (0.29 (0.12-0.69) and 0.19 (0.08-0.45), respectively), independent of age and smoking status. Similar results were found when groups were compared at equivalent latency times (groups I v II: 30-45 years; groups II v III: 20-25 years). Ageing, dyspnoea, past and current smoking, and radiographic abnormalities were associated with ventilatory impairment. Lower spirometric values were found in groups I and II compared to group III: lung function values were also lower in higher quartiles of latency and of cumulative exposure in these subjects.

CONCLUSIONS

Progressive improvement in occupational hygiene in a developing country is likely to reduce the risk of non-malignant consequences of dust inhalation in asbestos miners and millers.

Brain resistance to HSV-1 encephalitis in a mouse model

Brain resistance to intracerebral superinfections develops after a peripheral inoculation of neurovirulent viruses. Superinfection resistance combines specificity, toward the virus used for the peripheral inoculum, and short-term duration after the inoculum. In order to study this unusual combination, neurovirulent superinfections were made on albino Swiss mice previously infected with a nasal inoculum. A herpesvirus strain SC16, or a homologue recombinant virus carrying the reporter lac Z gene or a vesicular stomatitis virus (VSV) (a virus taxonomically unrelated to Herpesviridae) were used. The mice underwent a neurological examination and their survival rate was recorded. The brains superinfected with the reporter virus were stained for the beta-galactosidase reaction to trace the virus spread and the inflammatory infiltrates were characterized immunocytochemically. The results confirm and extend previous observations about virus specificity and short-term duration of superinfection resistance. They show, moreover, an enhanced brain inflammation with T-cells and macrophages infiltrating the tissue around microvessels, at a time when both neurovirulence and the spread of herpesvirus in the brain are reduced. The results suggest that the immune response to superinfection in the nervous tissue is enhanced by blood-brain barrier mechanisms that promote the timely extravasation of immune cells.

Elimination of Bax expression in mice increases cerebellar purkinje cell numbers but not the number of granule cells

Cerebellar Purkinje cells and granule cells have been studied extensively as models for investigating neuron-target interactions and the regulation of cell numbers in the developing central nervous system. Recent studies of transgenic mice that overexpress a human Bcl-2 transgene in Purkinje cells suggest both that programmed cell death plays an unexpected role in regulating Purkinje cell number and that Purkinje cells influence the number of granule cells. The role of cell death-related proteins and Purkinje-granule cell interactions in cerebellar development was investigated further in this study by counting the number of Purkinje and granule cells in knockout mutants with a deletion in the proapoptotic gene, Bax. The total number of Purkinje cells was estimated using stereological counting principles in six adult wild type mice, four hemizygous Bax +/- controls, and six Bax -/- knockout mutants. The total number of granule cells per cerebellum was estimated in three adult wild type mice, three hemizygous Bax +/- controls, and three Bax -/- knockout mutants. The number of Purkinje cells increased significantly by over 30% in the Bax -/- knockout mutants compared with wild type and hemizygote controls, whereas the number of granule cells was unchanged in the Bax -/- mutants. There was no change in the volume of the cerebellar cortex or in the size of Purkinje cell bodies in the Bax -/- mutants, implying that Purkinje cell density was increased in the Bax -/- mutants. The increase in Purkinje cell numbers in the Bax -/- knockout mice supports previous evidence that Purkinje cells undergo a period of naturally occurring cell death that is mediated at least in part by the cell death proteins Bcl-2 and Bax. The lack of an effect of Bax gene expression on granule cell numbers indicates that Bax is not an obligate participant in naturally occurring cell death in granule cells.

The microbial flora of the gastrointestinal tract and the cleaning of flexible endoscopes

Technologic advances in the last 30 years have resulted in the development of complex, expensive, and heat sensitive medical instrumentation, including flexible gastrointestinal endoscopes. Because of the design complexity and the region of use, gastrointestinal endoscopes present special challenges to cleaning. If instruments are not properly cleaned the disinfection or sterilization procedure can fail and increase the possibility of infection transmission from one patient to another. Although the cleaning process removes intestinal microflora, the washing process itself may introduce a saprophytic or environmental microbial flora. It has been repeatedly shown that endoscope cleaning, not the disinfection or sterilization procedure, controls the success of the reprocessing procedure.

Epidemic hypotension in a dialysis center caused by sodium azide

The water used for dialysate (dialysis fluid) in hemodialysis centers is produced by water treatment systems (WTS), which require careful and frequent monitoring. On November 3, 1988, nine patients receiving hemodialysis treatments at a single dialysis center suddenly developed hypotension within 30 minutes of onset of dialysis. Eight patients exhibited symptoms and two experienced syncopal episodes; there were no deaths. The incidence of dialysis-associated hypotension occurring within 30 minutes after dialysis onset for these patients was significantly higher during outbreak treatments than during preoutbreak (September 1 through November 2, 1988) treatments, (9 of 9 vs. 0 of 238, P less than 0.00001, Fisher's t-test). Sodium azide, a potent hypotensive agent, was identified as the probable contaminant within the WTS of the dialysis center at the time of the outbreak because: 1) it was mixed with glycerine as the preservative solution of each of the four ultrafilters that were put on-line in the WTS without rinsing, 12 hours before the outbreak; and 2) high levels of total organic carbons were detected from dialysis water collected at point-of-use sites at the time of the outbreak, suggesting contamination of the WTS with the sodium azide-glycerine preservative solution. To prevent similar occurrences, we recommend that ultrafilters (and other components of the WTS) be rinsed free of potentially toxic chemicals prior to use. Dialysis center personnel need to be aware of the potential affects that each modification of disinfection of the WTS may have upon the product water used to prepare dialysate for patient treatments.

Considerations on the malignancy of papillary meningioma. Clinico-pathological study of eight cases

Eight papillary meningiomas, out of a collection of 750 cases of meningiomas, have been studied clinically and anatomopathologically. 2 had long survival without recurrences, 2 died shortly after operation, 4 had one or more recurrences with death. The 2 cases with long survival showed, at microscopical examination, few mitoses. On the contrary, in the six cases come to death the histological features were characterized by marked pleomorphism, focal necroses and frequent typical and atypical mitoses. In these cases, the correlation between "more malignant" histological aspects and "more aggressive" clinical behaviour is undoubtedly suggestive.

Atypical and polymorphic angioblastic tumors of the central nervous system

Five central nervous system (CNS) polymorphic angioblastic tumors have been studied. Four were located in the posterior fossa and one involved the temporal lobe. In reviewing the literature, the authors point out the rarity of the supratentorial locations and of malignant hemangioblastomas. The clinical and anatomopathological peculiarities are discussed, as is the uncertain classification of two cases. The discrepancy between histology and outcome is focused upon in the other three cases. Finally, the diagnostic, prognostic, and nosographic difficulties posed by CNS angioblastic neoplasms are discussed.

The significance of atypical mitoses in malignant meningiomas

A group of 5 selected malignant meningiomas was studied in relation to the incidence and morphology of the mitoses. Beside a high mitotic rate many structural chromosomal abnormalities were observed. In agreement with other malignant onco-types previously studied, the authors suggest that atypical mitoses together with a tissue and cytological undifferentiation may be assumed to be an important prognostic criterium for meningiomas. The problem of malignancy in meningiomas has not been, so far, satisfactorily resolved, so that, in our opinion, the definition of even minimal details may be of some interest. For example, as it clearly appears from reviewing the literature on this sugject, no particular attention has been paid to the mitotic features. Referring to previous studies on the mitotic abnormalities in different malignant cerebral onco-types, the authors aimed to examine the various mitotic aspects in a limited group of tumors selected on the basis of clinical and histological malignancy.

[Study of the length of a stay of partial gastroduodenectomized patients]

The length of stay for 482 partial gastrectomy patients in the Servico de Cirurgia de Ribeirao Preto in the period from 1960 to 1974 is compared with that of four other neighbor hospitals for the year 1973. There was reduction in the length of stay during these years and it was more obvious when compared the other four hospitals. The authors claim that early discharge and home management should always be recommended and suggest an analysis of factors interfering with length of stay.