Ethical considerations for Forensic Genetic Frequency databases: First Report conception and development

The Forensic Databases Advisory Board (FDAB), an independent board that assists the International Society for Forensic Genetics (ISFG), has presented a First Report on ethical aspects of the following Forensic Genetic Frequency Databases (FGFD): EMPOP, STRidER and YHRD. The FDAB designed an ethical framework to evaluate the content of these FGFD, and the factors to be considered for retention and acceptance of submissions. The FDAB framework proposes to categorize submissions according to the risk of having contravened the universal ethical principles outlined by international organizations, and the guidelines adopted by the ISFG. The report has been open to discussion by the scientific community since 2023. Herein we present the conception and development of the First Report along with a summary of its content, with consideration of the feedback received.

The impact of lung ultrasound assessment during a whole lung lavage: A paediatric case of pulmonary alveolar proteinosis

Whole lung lavage (WLL) is the first-line treatment for pulmonary alveolar proteinosis. We hypothesized that lung ultrasound (LUS) would guide flooding during treatment in a 15-year-old boy. WLL of each lung consisted of instillation of saline followed by kinesiotherapy and fluid drainage. In the first WLL, the lung was repeatedly flooded until the lavage fluid was clear on macroscopic examination. During this process, LUS was used to visualise lung aeration. In the second WLL, we used LUS signs to guide the lavage volume. The appearance of the fluid bronchogram sign showed that saline infusion could be stopped earlier than in the first lavage. In conclusion, LUS helped monitor the different stages of controlled lung de-aeration during WLL and reduce the total amount of saline used. This technique will also reduce the risk of WLL-related complications.

Would surgical Apgar score be useful to predict postoperative complications after proximal femoral fracture surgery? - A retrospective cohort study

BACKGROUND

The surgical Apgar score (SAS) is a perioperative risk evaluation score, which considers intraoperative minimum heart rate, minimum mean arterial pressure and estimated blood loss. Although validated in multiple surgical fields, SAS remains quite controversial in the orthopedic one. The main purpose of this study was to investigate if SAS relates with the occurrence of complications during the first 30-days after proximal femoral fracture surgery.

METHODS

Retrospective study including all consecutive patients submitted to proximal femoral fracture surgery between January and July 2019. Patients with no information about SAS were excluded. Patients were divided in two groups, based on the occurrence of complications during the first 30 post-operative days and their SAS calculated. Receiver operating characteristic (ROC) curves were used to assess SAS power as a predictive model of complications.

RESULTS

Forty-two percent (n = 76) of the 181 patients included in the study developed complications during the first 30 postoperative days. Eight patients (4,4%) died during that period. The patient's mean age was 79 years and 30,9% (n = 56) were men. Heart failure, pacemaker use, chronic kidney disease, chronic obstructive pulmonary disease and dementia were significantly associated with post-operative morbidity. There was no significant correlation between SAS and the occurrence of complications during the first 30 postoperative days. The AUC of SAS as a predictive model for postoperative complications after proximal femoral fracture surgery was 0,522, being insufficient to be considered an accepted model of prediction.

CONCLUSION

Based on this study, we conclude that SAS is not predictive of the development of complications in the first 30 post-operative days in patients submitted to proximal femoral fracture surgery. However, other clinical factors have been identified as associated with postoperative morbidity. In the future, prospective-based studies with higher samples may better clarify the role of SAS in this context.

Postpartum headache after epidural anaesthesia: Who to blame?

INTRODUCTION

Epidural analgesia is considered the preferred analgesic choice during labour. Post dural puncture headache (PDPH) is considered a potential complication of this analgesic technique and is a frequently hypothesis for any headache occurring after delivery. It is essential that anaesthetists and obstetricians are familiar with other possible differential diagnosis for postpartum headache (PPH).

CASE DESCRIPTION

37-year-old female presented after delivery with intense occipital pulsatile headache associated with neck radiation, nausea and vomiting, hemodynamically stable and normal neurologic physical examination. Abnormalities in thyroid hormone levels were found. CT-scan findings suggested pituitary apoplexy.

DISCUSSION

There are many differential diagnoses for PPH and some are rarely considered, such as pituitary apoplexy. It is essential to differentiate signs and symptoms of each diagnosis, since many of them overlap.

CONCLUSION

Not all postpartum headaches are PDPH and the first suspected diagnosis may not always be accurate.

Support for decision-making on sharing health data for research: are data counsellors relevant?

Background

The implications of sharing one's health data are far-reaching. Potential applications of health data range from the delivery of treatments tailored to individuals' characteristics to improvements in public health, while also posing concerns about privacy, social justice and equity. Making informed decisions about health data sharing thus requires thorough consideration of the scientific, ethical and personal implications of donations. This study assessed participants' preferences regarding decision-making about health data sharing for research, including the need for support by data counsellors.

Methods

This observational cross-sectional study includes 159 patients and 479 carers followed at two reference centres for rare diseases in a Portuguese academic hospital, between June 2019 and March 2020. Participants were asked about preferred modes of decision-making: deciding on their own, deciding with support from another person, or delegating the decision to someone else. Those who responded the last two options also reported who they would choose for support or delegation: family or friends; a data counsellor; a professional with no specific training on data counselling; other. Data were analysed using descriptive and inferential statistics.

Results

The majority of respondents would prefer to decide with support (62%), 37% would prefer to decide on their own and 1% would opt to delegate the decision of sharing health data. Among those who expressed a preference for support, 60% would like to rely on a data counsellor. Carers, older and higher educated participants, and those with upper white-collar occupations and who were satisfied with their own health were significantly more likely to select data counsellors as their preferred source of support when engaging in decision-making about health data sharing for research (p < 0.05).

Conclusions

This study supports recommendations for the creation of a new professional specialty of health data counsellors.

Key messages

Most participants express the need for support in making decisions about health data sharing for research, with 60% preferring support from a data counsellor. As a new professional specialism, health data counselling can help to advance informed public participation in health research.

[Impact of hygienic and social distancing measures against SARS-CoV-2 on respiratory infections caused by other viruses]

OBJECTIVE

To control the pandemic caused by SARS-CoV-2, the implementation of social and hygienic confinement measures was determined in all countries. These measures reduce the circulation of most respiratory viruses that are transmitted preferentially by air and contact.

METHODS

The impact of these measures on non-Covid respiratory viruses during the period August-December 2020 and 2019 has been comparatively analyzed. To all nasopharyngeal aspirates that were negative against SARS-CoV-2 by RT-PCR and the suspicion of acute respiratory infection persisted, were subjected to a new RT-PCR that simultaneously and differentially amplifies 21 different respiratory viruses.

RESULTS

In the year of the pandemic, a 36.6% decrease was detected in the number of respiratory samples studied and 66% in their positivity in relation to 2019. All viruses showed reduction percentages of between 40-100%. The only viruses that circulated during and after national lockdown were rhinovirus (74.1%), adenovirus (10.1%), and enterovirus (9.6%).

CONCLUSIONS

The measures used to control the SARS-CoV-2 infection have also affected the community circulation of most respiratory viruses including influenza and respiratory syncytial virus.

Postpartum headache after epidural anaesthesia: Who to blame?

INTRODUCTION

Epidural analgesia is considered the preferred analgesic choice during labour. Post dural puncture headache (PDPH) is considered a potential complication of this analgesic technique and is a frequently hypothesis for any headache occurring after delivery. It is essential that anaesthetists and obstetricians are familiar with other possible differential diagnosis for postpartum headache (PPH).

CASE DESCRIPTION

37-year-old female presented after delivery with intense occipital pulsatile headache associated with neck radiation, nausea and vomiting, hemodynamically stable and normal neurologic physical examination. Abnormalities in thyroid hormone levels were found. CT-scan findings suggested pituitary apoplexy.

DISCUSSION

There are many differential diagnoses for PPH and some are rarely considered, such as pituitary apoplexy. It is essential to differentiate signs and symptoms of each diagnosis, since many of them overlap.

CONCLUSION

Not all postpartum headaches are PDPH and the first suspected diagnosis may not always be accurate.

Ultrasound-guided fascial plane blocks as unique anesthetic technique for total mastectomy in a covid-19 era: a case report

Introducción

Se han introducido recientemente técnicas de anestesia regional, para aportar analgesia en la cirugía de mama. Dichas técnicas son raramente utilizadas como anestesia primaria, debido a la complejidad de la inervación de la mama, con numerosas estructuras que pueden verse potencialmente alteradas durante la cirugía.

Caso clínico

Paciente femenino de unos 70 años con diagnóstico de carcinoma ductal invasivo en la mama izquierda, programada para mastectomía simple. Tras la evaluación anestésica e identificación de complicaciones cardiovasculares perioperatorias de alto riesgo, fue propuesta para cirugía con anestesia regional únicamente. Se realizó una combinación exitosa de bloqueo del nervio pectoral (Pecs II), bloqueo fascial pecto-intercostal (PIFB) y bloqueo ecoguiado del nervio supraclavicular.

Conclusión

Este es el primer caso que reporta una técnica novedosa en una paciente con enfermedad cardiopulmonar severa, a quien se practicó cirugía de mama en la era de la COVID-19.

Public preferences for involvement in the governance of health data

Background

Public involvement in the governance of epidemiological and public health studies can foster needs-driven research, enhance participants' recruitment, reduce attrition and improve the quality of and ethics in research and surveillance. However, it can also reinforce health inequalities if it fails to ensure public representation across socioeconomic gradients. This study aimed to assess patients' and carers' preferences for involvement in collective health data governance, and its associated factors, to strengthen the evidence base for policy development.

Methods

Between June 2019 and January 2020, 644 people (157 patients and 487 carers; participation rate=89.3%) followed at two reference centres for rare diseases in a university hospital from Northern Portugal were enrolled in an observational cross-sectional study. Data about willingness to participate in data governance was collected through four intersecting options: periodic or sporadic meetings, by either giving opinions (consultation) or participating in decision-making (deliberation). Data were analysed using descriptive and inferential statistics.

Results

From a total of 629 respondents, 39% are willing to get involved through at least one of the four participatory options and 16% do not want to participate. Patients and carers do not differ in their preferences for involvement. Sex and education are associated with willingness to participate, after adjustment for participant type (patient/carer), occupation and trust in national and international institutions (OR:1.60; 95%CI 1.05-2.45 for men vs. women and OR:1.65; 95%CI 1.07-2.56 for >12 vs. ≤12 educational years). Participants' preferred option for participation is consultative sporadic meetings (29.5%).

Conclusions

Anticipating which social groups are likely to become under-represented in participatory exercises is crucial to inform policy aimed at promoting inclusive involvement in health data governance.

Key messages

Men and higher educated participants are more willing to participate. Forecasting potential for subgroup under-representation is crucial to develop policy for inclusive participatory data governance.

Evaluation of ECG Interpretation Results Obtained by Computer and Cardiologists

In an international project investigators from 25 institutes are trying to establish a common reference library and evaluation methods for testing the diagnostic performance of various ECG computer programs and of cardiologists, based on ECG-independent clinical information. A first set of 500 validated ECGs was collected and analyzed by fifteen different computer programs and nine cardiologists, seven of who analysed the ECG and five the VCG. A coding scheme was used to map individual diagnostic statements onto a common set. Combined program and referee results were obtained by weighted averaging. Preliminary results indicate that the classification accuracy of several programs can still be improved. However, it was also apparent that the results of the best 12-lead ECG computer programs proved to be almost as accurate as the best of seven cardiologists in classifying seven main disease categories, i.e., normal, left, right and biventricular hypertrophy, anterior, inferior and combined myocardial infarction. Evaluation of rhythm statements and conduction disturbances was not included in the study. The data collection is still being pursued in order to reach over 1,000 cases. In this way a common diagnostic database is being established for comparative testing of diagnostic computer programs. This should lead to consumer protection and improve the accuracy and reliability of computerized electrocardiography.

Pollen allergenic potential nature of some trees species: a multidisciplinary approach using aerobiological, immunochemical and hospital admissions data

Trees are considered producers of allergenic pollen. The aims of this work were to characterize the aerobiology of the Platanus, Acer, Salix, Quercus, Betula and Populus pollen, linking it with monthly emergency hospital admissions and to identify the different reactivity levels in sensitized patients. This information would be of great importance to evaluate the convenience of changing the inventory of pollen producer trees related to the risk of allergenic reactions. The study was conducted in Porto, Portugal, from 2005 to 2007. Airborne pollen was sampled using a Hirst-type volumetric trap. The antigenic and allergenic properties of Acer negundo, Betula pendula, Platanus occidentalis, Populus hybrida, Quercus robur and Salix babylonica pollen, collected in public gardens or sidewalks, were investigated by sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) and immunological techniques using polysensitized-patient sera. Monthly hospital admissions of asthma or dyspnea related with respiratory diseases were obtained from the Emergency Room database of Hospital Geral de Santo António. Tree pollen and hospital admissions were positively correlated. Tree pollen peaked in March which coincides with the hospital admissions maximum. The highest binding affinity was observed with A. negundo, S. babylonica and P. occidentalis pollen extracts and the lowest with P. hybrida. Consistently, Acer and Platanus maximum airborne pollen concentrations were observed during March attaining levels considered moderate to high risk for allergenic reactions. Prominent bands with approximately 71, 35, 31, 22, 19, 16, 14, 13 and 11 kDa were revealed. A 52 kDa band was shared by all analyzed sera. High levels of airborne pollen and emergency hospital admissions were related. High binding affinity of specific IgE to pollen extracts of the most abundant tree pollen present in the atmosphere was observed. Patient sera revealed multiple similar allergenic bands shared by the different extracts. This multidisciplinary approach is useful in day-to-day medical practice to help in diagnostic, therapeutic and allergy alerting system adjusting.

Characterization of recombinant MSP5 Anaplasma marginale Havana isolate

Anaplasma marginale is the causative agent of bovine anaplasmosis, a disease of worldwide economic importance. Major surface proteins (MSPs) are involved in host-pathogen and tick-pathogen interactions and they have been used as markers for the genetic characterization of A. marginale strains and phylogenetic studies. The major surface protein 5 (MSP5) is highly conserved in the genus Anaplasma and in all isolates of A. marginale. The aim of the present work was to carry out the cloning, sequencing and characterization of the recombinant MSP5 Anaplasma marginale Havana isolate. The sequence of the msp5 gene of Anaplasma marginale Havana isolate with a size of 633 pb was determined (Acc. No. AY527217). This gene was cloned into pRSETB vector and expressed in Escherichia coli. The MSP5 protein was recognized by the monoclonal antibody ANAF16C1 and it showed a high similitude percent with the gene sequence described for other Anaplasma marginale isolates. These data are very important for the development of a diagnostic test for A. marginale using the MSP5 recombinant protein.

Increased serum adenosine deaminase activity in schizophrenic receiving antipsychotic treatment

Adenosine is an important modulator of the nervous system that has been implicated in the pathophysiology of schizophrenia. We studied peripheral adenosine metabolism by determining the activity of serum adenosine deaminase, which converts adenosine into inosine, and 5'-nucleotidase, which converts AMP into adenosine, in 26 DSM-IV male schizophrenic patients under antipsychotic monotherapy and 26 healthy volunteers balanced for age and race. Schizophrenic patients treated either with typical antipsychotics or clozapine showed increased serum adenosine deaminase activity compared to controls (controls=18.96+/-4.61 U/l; typical=25.09+/-10.98 U/l; clozapine=30.32+/-10.83 U/l; p<0.05, ANOVA) and 5'-nucleotidase activity was also increased in patients on clozapine. After adjusting for confounding factors, adenosine deaminase, but not 5'-nucleotidase, alterations remained significant particularly in the clozapine group. This result suggests that either altered adenosine metabolism is present in schizophrenic patients or is influenced by treatment with antipsychotics, particularly clozapine.

Production and biochemical characterization of the recombinant Boophilus microplus Bm95 antigen from Pichia pastoris

The new antigen Bm95 from the cattle tick Boophilus microplus was recently isolated, cloned and expressed in the methylotrophic yeast Pichia pastoris. The recombinant protein has shown to induce protection in cattle against infestations of B. microplus under controlled and production conditions. In this paper we report the production and large-scale purification of the Bm95 protein, following a simple and cost-effective process. The antigen was obtained highly aggregated, forming particles ranging from 26 to 30 nm and with purity higher than 80%. The process yield was 0.55 g of pure Bm95 protein per liter of culture. The 98% of the primary structure of the recombinant protein was verified by mass spectrometry. Three amino acid changes in comparison with the sequence deduced from cDNA were detected by LC-MS/MS. The antigen was also obtained N-glycosylated, as previously reported for heterologous protein expression in P. pastoris.

[Changes in cognitive function performance in patients after anesthesia]

This study evaluates the mental performance of 112 patients (ASA grade 1 and 2) submitted to Orthopaedic, Urologic, Gynecologic, General and ENT surgery in Santo Antonio General Hospital. These patients received different types of anaesthesia: General Balanced Anaesthesia--GBA (n = 80), Total Intravenous Anaesthesia--TIVA (n = 17) and Regional Anaesthesia--RA (n = 15). Cognitive function was tested using the mini mental state test (MMS), which was done 24 hours before and 24 hours after anaesthesia. There was a high correlation between pre and postoperative MMS scores (R = 0.94). Patients in the GBA group show a significant (p < 0.001) decrease in cognitive performance 24 hours after surgery in comparison to the preoperative test. No differences were observed between the pre and postoperative MMS tests in the TIVA and RA groups.

Control of ticks resistant to immunization with Bm86 in cattle vaccinated with the recombinant antigen Bm95 isolated from the cattle tick, Boophilus microplus

The recombinant Bm86-containing vaccine Gavac(TM) against the cattle tick Boophilus microplus has proved its efficacy in a number of experiments, especially when combined with acaricides in an integrated manner. However, tick isolates such as the Argentinean strain A, show low susceptibility to this vaccine. In this paper we report on the isolation of the Bm95 gene from the B. microplus strain A, which was cloned and expressed in the yeast Pichia pastoris producing a glycosylated and particulated recombinant protein. This new antigen was effective against different tick strains in a pen trial, including the B. microplus strain A, resistant to vaccination with Bm86. A Bm95-based vaccine was used to protect cattle against tick infestations under production conditions, lowering the number of ticks on vaccinated animals and, therefore, reducing the frequency of acaricide treatments. The Bm95 antigen from strain A was able to protect against infestations with Bm86-sensitive and Bm86-resistant tick strains, thus suggesting that Bm95 could be a more universal antigen to protect cattle against infestations by B. microplus strains from different geographical areas.

Vaccination against ticks (Boophilus spp.): the experience with the Bm86-based vaccine Gavac

The control of tick infestations and the transmission of tick-borne diseases remain a challenge for the cattle industry in tropical and subtropical areas of the world. Traditional control methods have been only partially successful and the parasites continue to result in significant losses for the cattle industry. Recently, vaccines containing the recombinant B. microplus gut antigen Bm86 have been developed. Our vaccine formulation (Gavac, Heber Biotec S.A., Havana, Cuba) has been registered and is commercially available in Cuba, Colombia, Dominican Republic, Brazil and Mexico. In controlled pen trials, Gavac has been effective for the control of artificial infestations of B. annulatus, B. decoloratus and chemical-sensitive and resistant B. microplus strains from Australia, Africa, America and Iran. In controlled field trials in Cuba, Brazil, Argentina and Mexico, Gavac has shown a 55-100% efficacy in the control of B. microplus infestations in grazing cattle 12-36 weeks after the first vaccination. Field trials under production conditions have been conducted in Cuba, Colombia, Brazil and Mexico in pure and cross-bred cattle herds. The application of Gavac has increased the time between acaricide treatments by an average of 32 /-21 days (P = 0.0005) resulting in important savings for the cattle industry. In Cuba, a cost-effectiveness analysis was conducted in more than 260000 animals. The cost-effectiveness analysis showed a 60% reduction in the number of acaricide treatments, together with the control of tick infestations and transmission of babesiosis, which resulted in savings of 23.4 dollars animal(-1) year (-1). These results clearly demonstrate the advantage of vaccination and support the application of Gavac for the control of Boophilus spp. infestations.

Integrated control of acaricide-resistant Boophilus microplus populations on grazing cattle in Mexico using vaccination with Gavac and amidine treatments

Throughout most of the twentieth century, tick infestations on cattle have been controlled with chemical acaricides, typically administered by dipping or spraying. This approach can cause environmental and residue problems and has created a high incidence of acaricide resistance within tick populations in the field. Recently we developed a vaccine against Boophilus microplus employing a recombinant Bm86 antigen preparation (Gavac), (Heber Biotec S.A., Havana, Cuba) which has been shown to induce a protective response in vaccinated animals. Here we show for the first time under field conditions a near 100% control of B. microplus populations resistant to pyrethroids and organophosphates, by an integrated system employing vaccination with Gavac and amidine treatments. This method effectively controls tick infestations while reducing the number of chemical acaricide treatments and consequently the rise of B. microplus populations resistant to chemical acaricides.

Field studies and cost-effectiveness analysis of vaccination with Gavac against the cattle tick Boophilus microplus

The control of tick infestations and the transmission of tick-borne diseases remains a challenge for the cattle industry in tropical and subtropical areas of the world. Traditional control methods have been only partially successful and the parasites continue to result in significant losses for the cattle industry. Recently, vaccines containing the recombinant Boophilus microplus gut antigen Bm86 have been developed. These vaccines have been shown to control tick infestations in the field. However, extensive field studies investigating the efficacy and cost-effectiveness of vaccination have not been reported and are needed to appraise the effect of this new approach for tick control. Here is reported the results of the application of Gavac in a field trial including more than 260,000 animals in Cuba. In this study the correlation between the antibody response to vaccination and the effect on ticks fertility is determined. Physiological status of the animals was found to affect the primary response to vaccination but not the antibody titers after revaccination. A cost-effectiveness analysis showed a 60% reduction in the number acaricide treatments, together with the control of tick infestations and transmission of babesiosis, which resulted in savings of $23.4 animal-1 year-1. These results clearly demonstrate the advantage of vaccination and support the application of Gavac for tick control.

Effect of vaccination with a recombinant Bm86 antigen preparation on natural infestations of Boophilus microplus in grazing dairy and beef pure and cross-bred cattle in Brazil

Current methods for the control of the cattle tick Boophilus microplus infestations are not effective and the parasite remains a serious problem for the cattle industry in tropical and sub-tropical areas. Recent advances have introduced the possibility for the immunological control of the parasite through the use of recombinant vaccines. Recently, it was shown that the recombinant vaccine Gavac (Heber Biotec S.A.) is able to control B. microplus populations in artificially infected grazing dairy cattle in Cuba. To assay the effect of the vaccine on a different B. microplus strain and under different ecological conditions, we conducted a trial in Brazil on grazing dairy and beef pure and cross-bred cattle under natural infestation conditions. A farm in the northeast of the state of Sao Paulo was selected and two groups of animals per breed were included in the experiment and were maintained grazing on separate but similar pastures. For each breed, one group was vaccinated with the vaccine Gavac and the second group was not vaccinated and was employed as a control. In vaccinated cattle, during 36 weeks of experiment, the average infestation rate was maintained below 78 ticks per animal while average infestation peaks (mean +/- S.E.) of 144 +/- 44 ticks per animal (for dairy cross-bred cattle) and 195 +/- 42 ticks per animal (for beef cross-bred cattle) were recorded in the control groups. Tick infestation rates showed statistical significant differences (p = 0.04) between both experimental groups throughout the experiment. These results clearly showed, as in the Cuban study, that the vaccine controlled tick numbers in successive generations in the field.

Evaluation of ECG interpretation results obtained by computer and cardiologists

In an international project investigators from 25 institutes are trying to establish a common reference library and evaluation methods for testing the diagnostic performance of various ECG computer programs and of cardiologists, based on ECG-independent clinical information. A first set of 500 validated ECGs was collected and analyzed by fifteen different computer programs and nine cardiologists, seven of who analysed the ECG and five the VCG. A coding scheme was used to map individual diagnostic statements onto a common set. Combined program and referee results were obtained by weighted averaging. Preliminary results indicate that the classification accuracy of several programs can still be improved. However, it was also apparent that the results of the best 12-lead ECG computer programs proved to be almost as accurate as the best of seven cardiologists in classifying seven main disease categories, i.e., normal, left, right and biventricular hypertrophy, anterior, inferior and combined myocardial infarction. Evaluation of rhythm statements and conduction disturbances was not included in the study. The data collection is still being pursued in order to reach over 1,000 cases. In this way a common diagnostic database is being established for comparative testing of diagnostic computer programs. This should lead to consumer protection and improve the accuracy and reliability of computerized electrocardiography.

Chlamydial infection in Papanicolaou-stained cervical smears

Infection by Chlamydia trachomatis was frequently observed in routine cytologic smears studied for cancer detection. Seventy-three smears from 187 Chlamydia-positive cases seen in a two-and-one-half-year period were reviewed to establish the relationship between C. trachomatis infection and the incidence of metaplastic and dysplastic cells. An inflammatory process with metaplastic cells was found in 72.6% of the smears and dysplastic cells in 16.4%. The Papanicolaou stain gave enough detail not only for the identification of the inclusions but also for the relation of different types of inclusions to the different stages of the life cycle of the microorganism.

Mitral valve prolapse and coronary artery disease. Clinical, hemodynamic, and angiographic correlations

Among 95 patients with angina pectoris and angiographically documented coronary artery disease (CAD), prolapse of the scallops of the posterior leaflet of the mitral valve (PLMV) was noted in 30 patients. Left ventriculograms in the right anterior oblique (RAO) projection revealed isolated prolapse of the posteromedial commissural scallop (PMCS) in 12 patients and the anterolateral commissural scallop (ALCS) in two patients. Seven patients had prolapse of both PMCS and ALCS, three had prolapse of the PMCS and middle scallop (MS), and six had prolapse of all three scallops of the PLMV. Left ventricular dilatation with increase trabeculations was observed in 19 patients. Contractility determined in a quantitative fashion by segmental motion analysis was markedly impaired in 29 patients. None of the patients had angiographic evidence of mitral insufficiency. Left ventricular dysfunction was documented in 28 patients by either elevated left ventricular end-diastolic pressure (LVEDP), low cardiac index (CI) or decreased ejection fraction (EF). In two patients in whom left ventricular contractility improved after aortocoronary by pass, previously prolapsed scallops could not be identified in the postoperative ventriculogram. Prolapsed PLMV is a frequent angiographic finding in patients with angiographically observed CAD. Impaired contractility of the ventricular myocardium and papillary muscles, left ventricular dilatation, and hypertrophy appear to play a significant role in the pathogenesis of this abnormality through distortion of the directional axis of the papillary muscles, asynergic contraction of the related free wall of the left ventricle, and changes in the normal spatial alignment necessary for mitral valve closure. The syndrome of papillary muscle dysfunction in patients with coronary artery disease represents a wider clinical spectrom than previously described.