IOTA simple rules for discriminating between benign and malignant adnexal masses: prospective external validation

OBJECTIVE

To determine the diagnostic performance of International Ovarian Tumor Analysis (IOTA) 'simple' rules for discriminating between benign and malignant adnexal masses.

METHODS

A prospective study was performed between January 2011 and June 2012. Eligible patients were women diagnosed with a persistent adnexal mass who presented to the participating centers. Four trainees evaluated the adnexal mass by transvaginal ultrasound under the supervision of an expert examiner. The trainee analyzed the mass according to IOTA simple rules and provided a diagnosis of benign, malignant or inconclusive. All women included in the study underwent surgery and tumor removal in the center of recruitment. Diagnostic performance was assessed by calculating sensitivity, specificity and positive (LR+) and negative (LR-) likelihood ratios.

RESULTS

A total of 340 women were included (mean patient age, 42.1 (range, 13-79) years). Of the tumors, 55 (16.2%) were malignant and 285 (83.8%) were benign. The IOTA simple rules could be applied in 270 (79.4%) cases. In these cases, sensitivity was 87.9% (95% CI, 72.4-95.2), specificity 97.5% (95% CI, 94.6-98.8), LR+ 34.7 (95% CI, 15.6-77.3) and LR- 0.12 (95% CI, 0.05-0.31).

CONCLUSIONS

Application of the IOTA simple rules yielded acceptable results in terms of specificity in the hands of non-expert examiners. However, with non-expert examiners there was a 12% false-negative rate, which is relatively high.

Polymorphisms of the angiotensinogen gene and the outcome of microalbuminuria in essential hypertension: a 3-year follow-up study

BACKGROUND

The objective of this study was to analyse the relationship of polymorphisms of the angiotensinogen (AGT) gene with the changes in microalbuminuria during 3 years of antihypertensive treatment in a group of young adults with essential hypertension.

METHODS

Essential hypertensives, less than 50 years old, never previously treated with antihypertensive drugs and in the absence of diabetes mellitus were included. After the initial evaluation, patients were treated using only nonpharmacological measures (n=23), only beta-blockers (n=26), only angiotensin-converting enzyme inhibitors (ACEi) (n=57) or a combination of treatments (n=25). The office blood pressure, biochemical profile and urinary albumin excretion (UAE) were measured at the beginning and then yearly. The polymorphism A-6G of the AGT gene located in the promoter region was analysed.

RESULTS

In total, 131 patients, 35 (27%) microalbuminurics, were included. Although no significant differences in systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting glucose and UAE were observed among genotypes at the initial examination, during the 3 years of antihypertensive treatment the slope values for the DBP, fasting glucose and UAE differed significantly despite no differences in the distribution of treatments being present. The subjects carrying the AA-6 genotype had the largest DBP decrease, but the lowest UAE reduction and the highest slope of glucose. Out of 35 initially microalbuminuric patients, 24 became normoalbuminuric and the lowest reduction rates were observed in subjects who carried the allele A-6. No interaction between the type of treatment and genotype was observed on the changes in UAE, BP or glucose values. In the subset of 57 patients treated with ACEi, the changes in UAE, BP and glucose had the same trend as was observed in the total population.

CONCLUSIONS

Subjects carrying the AA genotype of the A-6G AGT gene polymorphism are resistant to a reduction of microalbuminuria. Whether this can be attributed to a predisposition to glucose metabolic disturbance or not needs to be confirmed in further studies.

Polymorphism insertion/deletion of the ACE gene and ambulatory blood pressure circadian variability in essential hypertension

OBJECTIVE

The objective of the present study was to analyze the influence of the insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme on ambulatory blood pressure values and circadian variability in untreated patients with hypertension.

MATERIAL AND METHODS

Ninety-nine essential hypertensive patients, less than 50 years old (mean age 39.5+/-7.0 years), previously untreated with antihypertensive drugs were included. Twenty-four hour ambulatory blood pressure monitoring (ABPM) was performed with a Spacelabs (90202 and 90207) monitor, during a regular working day in unrestricted ambulatory conditions. The I/D polymorphism of the ACE was determined by PCR.

RESULTS

The distributions of genotypes were in Hardy-Weinberg equilibrium: I=17 (17%), ID=41 (41.5%), DD=41 (41.5%). No significant differences were present among the groups in terms of age, sex, and biochemical and lipid profiles. The average of 24-h ambulatory blood pressure was slightly higher in patients with the DD genotype as compared with patients with the II and ID genotypes. This was the result of higher nighttime blood pressure values, because no differences in blood pressure were observed during daytime. The systolic blood pressure (SBP) day:night ratio, as an estimate of circadian variability, was significantly lower in subjects homozygous for the D allele than it was in patients carrying the I allele (1.13+/-0.09 vs. 1.17+/-0.08, P=0.014). The subjects in the lowest tertile of the SBP day:night ratio, exhibited a higher frequency of the D allele when compared with those in the middle tertile (0.74 vs. 0.59, P<0.05) or with those in the highest tertile (0.74 vs. 0.54, P<0.01). By using two-way ANOVA with repeated measures, significant differences in SBP variation over time were observed when comparing homozygous for the D allele with subjects carrying the I allele (F=2.11, P=0.002).

CONCLUSIONS

Among the genotypes of the I/D polymorphism, subjects carrying DD genotype showed a blunted decline of the physiological nocturnal fall of blood pressure that was significant for SBP.

[Factors associated with changes in microalbuminuria during antihypertensive treatment]

BACKGROUND

The objective of the present study was to analyze the factors related with changes of microalbuminuria during antihypertensive treatment in patients with essential hypertension.

METHODS

One hundred and six patients (57 men, mean age 40.8 [SD 6.6] years) never treated with antihypertensive treatment were included. At the beginning and after one year, blood pressure biochemical profile and urinary albumin excretion (UAE) were measured. After the initial evaluation, 53 patients received angiotensin converting enzyme inhibitors (ACEi) and 53 beta-blockers (BB). Hydrochlorothiazide was added to achieve the blood pressure target < 140/90 mmHg.

RESULTS

The average of UAE was 32.1 (43.1) mg/24 h, and 41 (39%) patients had microalbuminuretics. After 12 months of treatment, a significative fall of systolic BP (-20.6 [8.03] mmHg, p < 0.001), and diastolic BP (-14.18 [10.34] mmHg, p < 0.001) were observed, whereas baseline glucose increases (3.08 [11.07] mg/dl, p = 0.006). The changes of UAE were only related with the baseline UAE values. Neither, age, sex, baseline diastolic BP and changes in diastolic BP were significantly related with the changes in UAE. In spite of similar mean BP reduction (medial BP 17.4 [10.9] vs 14.8 [10.4] mmHg), UAE only was reduced in patients treated with ACEi (LogUAE: 0.203 [0.872] mg/24 h; p < 0.04). In addition, in patients treated with BB a significative increase in baseline glucose (4.4 [12.3] mg/dl; p = 0.013) and uric acid (1.18 [4.18]; p = 0.031) were observed.

CONCLUSIONS

In patients with essential hypertension, changes in microalbuminuria depends of the initial UAE values and the kind of antihypertensive treatment. ACEi produced higher UAE reduction and lower derangement of the glucose metabolism than BB.

[Atypical primary biliary cirrhosis or autoimmune cholangitis?]

The term autoimmune cholangitis is used for a disease with clinical and pathological features of primary biliary cirrhosis (PBC), lack of anti-mitochondrial antibodies (AMA), presence of anti-nuclear antibodies (ANA), and good response to immunosuppresive therapy. The current knowledge of this condition is limited and it is not established whether or not it is a different syndrome from the CBP. We report a 51-year-old woman with chronic cholestasis, histological features of PBC, negative AMA and positive peripheral fluorescent ANA pattern, without response to prednisone.

[Insertion/deletion polymorphism of the gene encoding for angiotensin-converting enzyme and microalbuminuria in essential arterial hypertension]

BACKGROUND

To assess the influence of insertion/deletion polymorphism in the ACE gene on the microalbuminuria in essential hypertension.

PATIENTS AND METHODS

Seventy-nine patients with essential hypertension (37 males and 42 females) (mean age 39 [7] years, body mass index 28 [4] kg/m2), never treated with antihypertensive drugs were included in the study. Urinary albumin excretion (UAE) was assessed in two different days. Ambulatory blood pressure (BP) was assessed during 24 h period. Genotype ACE gene and gene frequencies were determined by an assay based on the polymerase chain reaction (PCR).

RESULTS

The distribution of phenotypes was: II = 14 (17%), ID = 32 (40%) and DD = 33 (43%). The mean for UAE tended to be higher in the DD group (53.82 [88.4] mg/24 h) than ID (27.8 [39.6] mg/24 h) and II (23.8 [16.7] mg/24 h). Likewise, the average for UAE were higher in the DD group than in the II + ID group (26.6 [34.0] mg/24 h) (p = 0.06), although the differences did not achieved statistical significance. The relationship between log UAE and 24-hour mean BP was significantly higher in the DD group (r2 = 0.232; p = 0.005) than that observed in the other groups (r2 = 0.060; p = 0.101).

CONCLUSIONS

In the present study with young patients with essential hypertension, in DD genotype, UAE seems to be higher and more dependent of BP levels than in the other hypertensives.

[Clinical manifestations of Stenotrophomas (Xanthomonas) maltophilia infection]

OBJECTIVE

Stenotrophomonas maltophilia (SM) is a gram-negative bacillus whose incidence like nosocomial pathogen has been incremented in the last years, especially in immunocompromised patients, subjected to invasive procedures and those receiving broad-spectrum antimicrobial therapy.

METHOD

We report 15 isolations of SM between 1994-1996.

RESULTS

The criteria for SM infection were fulfilled by 9 patients (60%), and 6 patients (40%) were colonized. The mean age of the patient was 60 +/- 12 years. Major predisposing factors in infections included venous catheterization (100%), prior surgery (86%), residence in ICU (80%), prior antibiotic therapy (80%) and intubation (66%). The most common underlying disease were heart disease (60%), treatment with immunosuppressors and/or steroids (46%) and chronic lung disease (46%). Ten cases (66%) had polymicrobial culture. The mortality rate was 40%. Risk factors associated with fatal outcome included the following: chronic lung disease (p = 0.043), nasogastric catheterization (p = 0.01), urinary tract catheterization (p = 0.02), intubation (p = 0.04) and the presence of pneumonia or sepsis by SM (p = 0.02). The most active agents were colistina (100%), cotrimoxazol (71%) and ceftazidima (53%). The isolates were highly resistant to first and second-generation cephalosporins (100%) tetracyclines (86%), aztreonam (91%) and imipenem (71%).

CONCLUSION

SM cause a wide range of clinical syndromes and is more likely to cause infection or colonization in patients who have underlying disease. Due to its inherent multiple-antimicrobial resistance, it would appear its potential as a nosocomial pathogen will continue to increase. Therapy of patients should include cotrimoxazole.

[Acute hepatocellular lesion induced by amoxicillin-clavulanic acid]

Since first description in 1988, numerous cases of amoxycillin-clavulanic acid hepatotoxicity have been reported. Most of them are cholestatic hepatitis. A case of acute hepatocellular injury by amoxycillin-clavulanic acid is reported in a 23-years-old male, with a favourable outcome after 18 weeks.