Rapid diagnosis and treatment of TIA results in low rates of stroke, myocardial infarction and vascular death

INTRODUCTION

The 90-day risk of cerebral infarction in patients with transient ischaemic attack (TIA) is estimated at between 8% and 20%. There is little consensus as to which diagnostic strategy is most effective. This study evaluates the benefits of early transthoracic echocardiography (TTE) with carotid and transcranial Doppler ultrasound in patients with TIA.

METHODS

Prospective study of patients with TIA in an emergency department setting. Demographic data, vascular risk factors, and ABCD(2) score were analysed. TIA aetiology was classified according to TOAST criteria. All patients underwent early vascular studies (<72hours), including TTE, carotid ultrasound, and transcranial Doppler. Primary endpoints were recurrence of stroke or TIA, myocardial infarction (MI), or vascular death during the first year.

RESULTS

We evaluated 92 patients enrolled over 24 months. Mean age was 68.3±13 years and 61% were male. The mean ABCD(2) score was 3 points (≥5 in 30%). The distribution of TIA subtypes was as follows: 12% large-artery atherosclerosis; 30% cardioembolism; 10% small-vessel occlusion; 40% undetermined cause; and 8% rare causes. Findings from the early TTE led to a change in treatment strategy in 6 patients (6.5%) who displayed normal physical examination and ECG findings. At one year of follow-up, 3 patients had experienced stroke (3.2%) and 1 patient experienced MI (1%); no vascular deaths were identified.

CONCLUSIONS

In our TIA patients, early vascular study and detecting patients with silent cardiomyopathy may have contributed to the low rate of vascular disease recurrence.

Impact of liposomal amphotericin B on renal function in critically ill patients with renal function impairment

OBJECTIVE

To assess the tolerability of liposomal amphotericin B (L-AmB) in critically ill patients with elevated serum creatinine concentrations (Cr) (> 1.5 mg/dL) at starting L-AmB therapy.

METHODS

Retrospective, multicenter, comparative study of two cohorts of critically ill patients treated with L-AmB during 3 or more days, the difference between them was the level of Cr at the beginning of treatment. A cutoff value of Cr of 1.5 mg/dL was established. Patients undergoing extrarenal depuration procedures before or 48 hours after starting L-AmB were excluded. The primary endpoint was the difference between Cr values at the end of treatment as compared with Cr at starting L-AmB. Secondary endpoints were treatment-related withdrawals, need of extrarenal depuration techniques, and treatment-related severe adverse events. Demographic data, underlying illness, indication of L-AmB therapy, concomitant risk factors of nephrotoxicity, and vital status at ICU and hospital discharge were recorded.

RESULTS

A total of 122 patients admitted to 26 ICUs (16 with Cr > 1.5 g/dL; 106 with normal Cr levels) were recruited. Main reasons for the use of L-AmB in both groups were the broad spectrum of the drug and the presence of hemodynamic instability. L-AmB was administered as first-line treatment in 68.8% of patients with elevated Cr and in 52.8% with normal Cr. The APACHE II score on ICU admission was 25 in patients with elevated Cr and 17 in those with normal Cr values (p < 0.001). Duration of treatment with L-AmB was 16 and 12 days in patients with elevate and normal Cr values, respectively, with a mean dose of 3.5 vs 3.9 mg/kg/day. The use of concomitant nephrotoxic drugs, mortality rate, and ICU and hospital length of stay were similar in both cohorts. In patients with renal function impairment at the initiation of L-AmB treatment, an absolute decrease of Cf-Ci of 1.08 mg/dL was observed (P < 0.001). A decrease of Cr levels to normal limits was observed in 50% of the patients; in 37.5% of patients there was a decrease but normal levels were not achieved, whereas a Cr increased occurred in only one (6.25%) patient. None of the patients required withdrawal of L-AmB or use of extrarenal depuration procedures. Treatment-related severe adverse events were not reported.

CONCLUSIONS

In critically ill patients with impaired renal function, the impact of L-AmB on renal function was minimal. L-AmB can be used for the treatment of fungal infections in critically ill patients independently of renal function at the initiation of treatment.

P2-09-10: Giant or Windmill? 18F-FDG-PET/CT Semi-Quantitative Parameters and Biological Prognostic Parameters in Women with Breast Cancer Treated with Neoadjuvant Chemotherapy: A Multicentric Study in La Mancha

Background: To analyze the possible predictive-prognostic value of 18F-FDG-PET/CT to evaluate response to primary preoperative neoadjuvant (NA) chemotherapy (CT) in women with breast cancer (BC) a multicenter study is being conducted in most Hospitals in Castilla - La Mancha (central Spain). As per protocol a PET/CT study has to be conducted prior to 1st cycle, after 2nd cycle and at the end of induction CT. We report here the initial results with the correlation between the PET/CT results and pathological-radiological-clinical findings prior to NA CT.

Aim: To analyze the correlation between 18F-FDG uptake assessed by PET/CT and histopathological and inmunohistochemical prognostic factors in BC prior to NA CT.

Material and methods: 68 women diagnosed of BC (36 with locally advanced BC) were prospectively evaluated. PET/CT was requested in the initial staging previous to NA CT. Clinical and metabolic stages were assessed according to TNM classification. All biological prognostic parameters, such as ER, PR, p53 and c-erbB-2 expression, proliferation rate (Ki-67), and grading (SBR) were determined from tissue of the primary tumour prior to NA CT. All patients underwent an 18F-FDG PET/CT with a dual-time-point acquisition performed in the early phase 1 h after FDG administration (PET-1) and in the delayed phase 3 h after FDG administration (PET-2). Both examinations were evaluated qualitatively and semiquantitatively with calculation of SUVmax values in PET-1 (SUV-1) and in PET-2 (SUV-2) and the percentage variation of the standard uptake values (retention index) between PET-1 and PET-2. Metabolic, clinical and biological parameters were correlated. Student, ANOVA and Bonferroni tests were used to compare the means, chi-score to compare proportions and Pearson correlation to compare two quantitative variables.

Results: A positive relationship was found between the SUVmax, tumour size, clinical and metabolic stages. SUV-1 and SUV-2 values showed significant statistical correlation (p&lt;0.05) with PET stage and tumour size assessed by PET. On the contrary, the retention index showed relation with clinical stage (p&lt;0.05). About the biological parameters, retention index showed the best results with positive and significant relation (p&lt;0.05) with histological grade, ER status, Ki-67 and c-erbB-2 expression. Isolated SUV values only showed significant relation to Ki-67 expression.

Conclusion: The retention index showed the best correlation with biological and clinical parameters compared to isolated SUVmax values. It may be useful as a predictive marker of tumor biological behavior. Nevertheless these are only the results of PET/CT prior to NA CT, with longer follow up we hopefully will be able to look at the correlation between PET/CT and radiological, clinical and pathological response after NA CT.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-09-10.

Hartmann's operation: how often is it reversed and at what cost? A multicentre study

AIM

The study evaluated the rate of reversal of Hartmann's operation after the initial surgery and its morbidity.

METHOD

A multicentre retrospective study was carried out in seven hospitals in the Valencia area of patients who underwent Hartmann's operation from 2004 to 2008. The incidence of reversal was determined.

RESULTS

Four hundred and fifty-two patients of mean age 67.5 ± 15.4 years were included, of whom 78.8% had an emergency operation. The most common diagnosis was cancer (58.6%), although diverticulitis predominated in the emergency setting. At a median follow up of 44 months, 159 (35.2%) patients had undergone reversal, including 16.6% after elective surgery and 40.4% after an emergency Hartmann's procedure (P < 0.001). The most frequent reason why reversal was not done was death (74 [25%] patients). Patients undergoing reversal were younger and had a low ASA risk. Trauma was associated with a higher rate of reversal, followed by diverticular disease. Surgery was performed at a median of 10 months. An open approach with stapled anastomosis was used in most cases. The mortality was 3.5%. Complications occurred in 45.2%, with a 6.2% rate of anastomotic leakage. Complications were associated with age, diabetes mellitus, arteriosclerosis, obesity, smoking, chemotherapy and COPD.

CONCLUSION

Hartmann's reversal was performed in a small percentage of patients, mostly including those with benign disease. It had a significant morbidity.

Linking δ 15N and histopathological effects in molluscs exposed in situ to effluents from land-based marine fish farms

Histopathological alterations can indicate time-integrated impacts on organisms stemming from alterations at lower biological organisation levels. Long-term (native mussels) and short-term (transplanted clams) changes in the tissues of molluscs exposed to the effluents from two land-based marine fish farms (LBMFFs) were determined. Histological alterations were related to the δ(15)N isotopic signal measured in mussels and macroalgae. Effluents from LBMFFs were found to cause severe and moderate gill filament exfoliation in clams and mussels, respectively. Some transplanted clams showed severe degrees of hemocytic phagocytosis in gonads and connective tissue. In an attempt to semi-quantitatively summarize the observed histopathological alterations, a weighted index of damage (WID) was calculated for each type of alteration, species and sampling site. The WID was clearly related to the δ(15)N descriptor of exposure. Further studies aimed at standardizing this relationship may establish critical thresholds of the descriptor for its implementation within environmental monitoring plans for LBMFFs.

Cross-sectional area of the tendons of the tarsal region in Standardbred trotter horses

REASONS FOR PERFORMING STUDY

The assessment of a normal range for cross-sectional area (CSA) of tendons in the tarsal region is important in order to use them as reference values in the identification of pathological changes of dimensions.

OBJECTIVES

To provide normal reference values for the CSA of the tendons of the tarsus of Standardbred trotter horses (STH) by means of ultrasonography.

METHODS

Transverse echographic images of the tendons were obtained at different levels proximodistally; these images were digitised and CSA values (mean ± s.d.) were obtained for each structure.

RESULTS

The largest structure corresponded with the lateral digital flexor/caudal tibial tendon complex at Level 1 and the smallest was the medial digital flexor tendon at Level 4. Almost all tendons showed a slight decreasing in their CSA when crossing the tarsus.

CONCLUSIONS

The normal CSA values of tendinous structures in the tarsal region of the STH are reported. These data could be used as anatomical references.

POTENTIAL RELEVANCE

The establishment of reference values could serve as a tool to discriminate between normal and abnormal dimensions of tarsal tendons in STH. Other horse breeds should need their own reference values.

Persistent microalbuminuria after treatment with renin-angiotensin axis blockers: causes and results of treatment intensification

AIMS

The first phase of this study aimed to determine the causes of persistent microalbuminuria after treatment with renin-angiotensin axis (RAA) blocking drugs. In a second phase we tried to determine if strict control of blood pressure and intensive RAA blockade could induce remission or reduction of microalbuminuria in clinical (primary care) practice.

PATIENTS AND METHODS

The study included both diabetic patients and non-diabetic hypertensive patients treated with RAA drugs in the presence of microalbuminuria. 211 patients were recruited (mean age 66.6±11.3 years, 111 men, 117 were diabetic). In the first phase treatment was optimized at standard doses. In the second phase treatment was increased during a three months period to reach a blood pressure (BP) < 130/80 mmHg by adding other antihypertensive treatment and to obtain maximal RAA blockade using long-acting drugs, increased dosage, or adding further medication at night.

RESULTS

Initial mean BP was 141±16/81±11 mmHg. BP control was unsatisfactory (control of systolic blood pressure [SBP] 19.3%; diastolic blood pressure [DBP] 37.6%). Dosage of RAA blocking drugs was inadequate in 21% of patients. Only 27.4% of patients were taking antihypertensive drugs at night. 30.1% of patients took once daily short acting drugs. During the studymean SBP was reduced to 137±13 mmHg (p < .001) and DBP decreased to 79±10 mmHg (p < .001). Control of SBP improved to 24.5% and DBP control went to 44.4%. Mean microalbuminuria decreased from 64.4±47.0 mg/day to 50.1±53.0 mg/day (p < .001) and the prevalence of microalbuminuria was reduced to 59.1%.

CONCLUSIONS

Persistent microalbuminuria was associated with poor blood pressure control and inadequate drug dosage. Low frequency of administration of drugs at night and inappropriate once-daily pills intake were frequent. Strict control of blood pressure and intensive RAA blockade significantly reduced the prevalence of microalbuminuria.

Medical and surgical management of a dystocia because of foetopelvic disproportion in an African lioness (Panthera leo)

Medical and surgical management of a foetopelvic dystocia in an African lioness (Panthera leo) and the post-operative complications are reported. A caesarean section was performed to extract an oversize foetus blocked at the cervical canal; the lioness died 36 h after surgery. At necropsy, an abdominal effusion with sero-haemorrhagic fluid was observed, along with a fibrinopurulent exudate adhered to the serosal surfaces of the pelvic and abdominal cavities. In addition, the pelvic symphysis was not cartilaginous, but formed a firm and rigid joint between the pubis and ischium of each hip. The macroscopic and microscopic findings confirmed the presence of metritis, vaginitis and peritonitis. Dystocia may be caused by the premature ossification of the pelvic symphysis, reducing the dimensions of the pelvic cavity.

Oocyte structure and ultrastructure in the Mexican silverside fish Chirostoma humboldtianum (Atheriniforme: Atherinopsidae)

The structural and ultrastructural features of gonads from endemic Mexican fish have received scarce attention. This study describes the histological and ultrastructural characteristics of oocyte from Chirostoma humboldtianum. The ovary is asynchronic, and as such, most phases of oocyte development are found in the same ovary. The complete process of oogenesis was divided in five stages: oogonium and folliculogenesis, primary growth, cortical alveoli and lipid inclusions, vitellogenesis, and maturation. The presence of big filaments, which appear at the end of primary growth, induces some common follicular adaptation. During primary growth, abundant ribosomes, the rough endoplasmic reticulum, and mitochondria are grouped in the cytoplasm. At the end of this stage, the Z1 layer of the chorion is developed, while microvilli start to be evident. In the cortical alveoli and lipid droplets phase, intense PAS positive vesicles, some of them containing nucleoid material, are observed in the peripheral cytoplasm and the lipid droplets take a more central position. In vitellogenesis, the proteic yolk accumulates in a centripetal way while the chorion is completely formed. During maturation, the germinal vesicle migrates to the animal pole, meiosis is restored, and there is nuclear breakdown. The oocyte increases its size and holds some oil droplets and a big fluid mass of yolk. On the outside, filaments completely surround the oocyte.

The Hispanic Women's Social Stressor Scale

Measurement of social stressors among Hispanic women is a growing and important area of study, particularly in terms of understanding explanatory mechanisms for health disparities. This study involved adaptation of the Hispanic Stress Inventory and the Latin American Stress Inventory to create a measure of social stressors specifically for both immigrant and nonimmigrant Hispanic women. The measurement development process included review of existing scales, focus groups with Hispanic women (U.S.- and Mexico-born) in New Mexico, and creation, pilot testing, and factor analysis of a 41-item scale. Results indicate that the Hispanic Women's Social Stressor Scale is a reliable and valid measure of the social stressors experienced by U.S.-born and Mexico-born Hispanic women in the Southwest. Factor analyses revealed six reliable and conceptually distinct sub-scales of social stressors: immigration, socioeconomic, racism-related, familial, parental, and employment. Convergent and criterion validity were supported.

Real time modulable multifocality through annular optical elements

We present and analyze new multifocal optical elements based on an annular distribution of the transmittance. These elements provide selectable number of foci and can be designed to work between two fixed positions or even to provide extended focal depth. The energy of the foci can be modulated through a single parameter that controls the area of each ring. In our study we analyze the quality of the peaks and also the limit number of foci that can be obtained. The properties shown by these elements make them usable in instrumental optics or in ophthalmic optics, as new intraocular implants, where multifocal elements are required. The implementation has been done on a twisted nematic spatial light modulator, thus allowing real time reconfiguration of the element.

Three dimensional analysis of chromatic aberration in diffractive elements with extended depth of focus

The paper presents the polychromatic analysis of two diffractive optical elements with extended depth of focus: the linear axicon and the light sword optical element. Chromatic aberration produces axial displacement of the focal segment line. Thus, we explore the possibility of extending the focal depth of these elements to permit superposition of the chromatic foci. In the case of an axicon, we achieve an achromatic zone where focusing is produced. In the case of the light sword element, we show that the focusing segment is out of axis. Therefore a superposition of colors is produced, but not on axis overlapping. Instead, three colored and separated foci are simultaneously obtained in a single plane. Three dimensional structures of the propagated beams are analyzed in order to provide better understanding of the properties and applications of such elements.

Optical Analysis of PresbyLASIK Treatment By a Light Propagation Algorithm

PURPOSE

To evaluate the changes in the optical quality of corneas of hyperopic patients operated using central multifocal presbyLASIK treatment through the study of light patterns around the retinal plane.

METHODS

This study included eight hyperopic eyes that underwent central presbyLASIK surgery with Presby-one software using an H. Eye Tech Technovision excimer laser platform. Mean patient age was 57 years. Mean preoperative spherical equivalent refraction was 1.28 +/- 0.87 diopters (D). Mean distance decimal visual acuity with correction was 1.02 +/- 0.13 and without correction was 0.37 +/- 0.15. The optical quality was characterized by the Strehl ratio, the spot size on the retina, and objective decimal visual acuity calculated based on measured corneal topography using Fresnel propagation algorithm based on a realistic eye model.

RESULTS

The postoperative spherical equivalent refraction was -0.55 +/- 0.48 D. The distance decimal visual acuity with correction was 0.94 and without correction was 0.70. The pseudoaccommodation range was 1.60 +/- 0.40 D. A good Pearson correlation coefficient was obtained (r2 = 0.86) for the linear fit between the real and calculated decimal visual acuity for the eight eyes. The Strehl ratio value on the retinal plane increased after the surgery by a mean factor of 4.7.

CONCLUSIONS

With a complete characterization of the eye and a complete propagation algorithm (that takes into account all refractive surfaces in the eye at the same time), it is possible to evaluate the optical quality in eyes of patients who have undergone central presbyLASlK treatment.