[Retrospective studies of pregnancies after assisted medical reproduction from 2001-2009 and Central Hospital in Luxembourg (part 2)]

The first chapter analyses the ART methods of the Centre Hospitalier of Luxembourg, in the department of reproductive medicine between 2001 and 2009. The second chapter examines the techniques individually, their influence on pregnancy outcomes, the complications on offsprings and their health. The results coincide with literature in that risks are acceptable as long as good medical and biological conditions are maintained. Multiple pregnancies remain the most frequent complication, particularly once out of IVF. These are analysed separately as well as the pregnancies after egg and semen donation.

An automatic Method to identify and extract information of DNA bands in Gel Electrophoresis images

This paper presents a system for the automatic processing of Digital Images obtained from Gel Electrophoresis. The system identifies automatically the number and the location of lanes in the digital image, as well as the location of bands on each lane, without any intervention from the user. A reference lane with a know substance is used to compute the molecular weight of the observed (unknown) bands. The system performance was tested using 12 images, obtained from 4 gels with 3 different exposures. A total of 5443 bands were tested in 12 images, 672 reference / observed lane pairs. The average error in the estimation of molecular weight of 9.2%.

Pulmonary tuberculosis in adolescents: radiographic features

We studied radiographic features of pulmonary tuberculosis (PTB) described in the report forms for 907 adolescents from two Brazilian cities. A descriptive analysis showed that the most common radiographic lesions were post-primary tuberculosis (53.3%), tuberculous expansile pneumonia (27%) and primary complex with adenomegaly (1.8%). Cavitary lesions occurred in 67/243 (27.6%) patients aged 0-15 years and in 116/321 (36.1%) adolescents aged 16-19 years (P = 0.031). Most of the PTB cases had forms similar to those in adults.

[Large vessel vasculitis in a patient with fever of unknown origin]

Fever of unknown origin (FUO) is a challenging diagnosis. Recently, 18F-fluorodeoxyglucose positron-emission tomography (FDG-PET) has emerged as an useful exam to its diagnosis. The authors present a case of a 64-years-old woman with an aortic mechanical valve that was admitted to the internal medicine department because of fever, weakness and weight loss of 2 months duration. Her physical examination was unremarkable. Laboratory findings showed microcytic anemia, no leukocytosis, and elevated C-reactive protein and erythrocyte sedimentation rate. Microbiology, immunology and imaging studies were normal. A FDG-PET was performed, which showed 18F-FDG uptake in aorta and its branches arterial wall. Treatment with corticosteroids was started with good response. This exam, although not sensitive for temporal arteritis when only smaller vessels are involved, permits the diagnosis of large vessel vasculitis with involvement of arteries that can not be biopsied.

Incidence of humoral sensitization in HLA partially mismatched hematopoietic stem cell transplantation

As part of the 15th International Histocompatibility and Immunogenetics Workshop (IHIWS), seven centers participated in a collaborative project to determine whether any significant humoral sensitization occurred post-transplant among recipients of HLA partially mismatched hematopoietic cell transplants (HCTs). A total of 140 donor/recipient pairs were enrolled with a total of 367 pre-and post-transplant sera analyzed. The majority of the samples (69.1%) were obtained within 30-90 days post-HCT. HLA-specific antibodies were defined using single antigen bead assays on a Luminex platform with a positive cutoff value of 1000 normalized median fluorescence intensity (MFI). There was an overall incidence of post-HCT sensitization toward donor HLA mismatches of 5.7%; however, all cases were among recipients of one HLA haplotype-mismatched grafts under nonmyeloablative, pre-transplant conditioning. Among the one haplotype-mismatched recipients, 15.7% (8/51) developed donor HLA-specific antibodies and 29.4% also had antibodies directed toward third party HLA antigens. Among the donor-specific antibodies, 9.8% were directed toward HLA class I antigens; 7.8% were against class II antigens; and 2.0% had both class I and II specificity. The relative strength of post-transplant antibodies was low with no significant difference in the mean maximum MFI values between third party and donor-specific antibodies. Because only a small number (10.2%) of the post-transplant samples were obtained 180 days or more post-HCT, longer term study is needed to evaluate any clinical relevance of these low-to-moderate levels of donor-specific antibody in one haplotype-mismatched recipients, as well as to determine whether any other antibodies occur at later times.

Adding gabapentin to a multimodal regimen does not reduce acute pain, opioid consumption or chronic pain after total hip arthroplasty

BACKGROUND

Gabapentin (GPN) is effective in reducing post-operative pain and opioid consumption, but its effects with regional anesthesia for total hip arthroplasty (THA) are not known. We designed this study to determine whether (1) gabapentin administration reduces pain and opioid use after THA using a multimodal analgesic regimen including spinal anesthesia; (2) pre-operative administration of gabapentin is more effective than post-operative administration.

METHODS

After REB approval and informed consent, 126 patients were enrolled in a double-blinded, randomized-controlled study. Patients received acetaminophen 1 g per os (p.o.), celecoxib 400 mg p.o. and dexamethasone 8 mg intravenously, 1-2 h pre-operatively. Patients were randomly assigned to one of three treatment groups (G1: Placebo/Placebo; G2: GPN/Placebo; G3: Placebo/GPN). Patients received gabapentin 600 mg (G2) or placebo (G1 and G3) 2 h before surgery. All patients had spinal anesthesia [15 mg (3cc) of 0.5% hypobaric bupivacaine with 10 microg of fentanyl]. In the post-anesthetic care unit, patients received gabapentin 600 mg (G3) or placebo (G1 and G2). On the ward, patients received acetaminophen 1000 mg p.o. q6h, celecoxib 200 mg p.o. q12h and a morphine PCA device. Patients were interviewed 6 months post-surgery to determine the incidence and severity of chronic post-surgical pain.

RESULTS

Mean+/-SD cumulative morphine (mg) consumption (G1=49.4+/-24.8, G2=47.2+/-30.1 and G3=56.1+/-38.2) at 48 h and pain scores at 12, 24, 36 and 48 h post-surgery were not significantly different among the groups [G1 (n=38), G2 (n=38) and G3 (n=38)]. Side effect profiles were similar across groups. Six months after surgery, the number of patients who reported chronic post-surgical pain (G1=10, G2=12 and G3=9) and the severity of the pain (G1=4.2+/-2.9, G2=4.1+/-2.2 and G3=4.9+/-2.2) did not differ significantly among the groups (P>0.05).

CONCLUSIONS

A single 600 mg dose of gabapentin given pre-operatively or post-operatively does not reduce morphine consumption or pain scores in hospital or at 6 months after hip arthroplasty within the context of spinal anesthesia and a robust multimodal analgesia regimen.

French Infobutton: an academic and business perspective

Infobuttons are context-specific links between clinical information systems and other online information resources. The objective of this study is to describe a French Infobutton, which will be sold in the French-speaking Health Information market.

Communication of information to patients with inflammatory bowel disease: A European Collaborative Study in a multinational prospective inception cohort

BACKGROUND AND AIMS

Communication to patients of information about their disease has become increasingly important in modern medicine, and particularly with chronic nonfatal disorders like inflammatory bowel disease (IBD), but the subject is not adequately researched or understood.

METHODS

We studied the media and preferences for communication of information in a multi-national community-based inception cohort of European and Israeli patients with IBD and 10 years follow-up, using structured questionnaires categorizing demographics, disease status, current and preferred sources of information, use of electronic media, role of patients' associations, and satisfaction level.

RESULTS

The 917 patients completing the questionnaire were derived from northern (60%) and southern (40%) countries. The mean age was 48.3 years (62% under 50 years); 51% were males; 67% had ulcerative colitis, 33% Crohn's disease. Sixty-six percent of patients designated the specialist as their primary source of information, 77% indicated satisfaction with their current information, and 65% reported not receiving information about medical treatment in the past year. Patient concerns were about new research into their illness (64%), medical treatments (58%), risks and complications (51%) and genetics (42%). Preferred sources of information were paper bulletin (76%), electronic media (30%) and international organization (79%). Diagnosis (ulcerative colitis or Crohn's disease), gender, education level and country impacted significantly on patients' choices.

CONCLUSIONS

In providing health care information to patients with IBD their individual attitudes and preferences must be considered. There should be greater roles for IBD patients' associations and international IBD-research organizations, and an increasing use of electronic media.

Use of super-concepts to customize electronic medical records data display

Patient medical record systems (MRS) merely offer static applications, in which mostly unstructured text is linked to coded data. In these applications the more common presentation is a time oriented one, which does not allow easily for data and information retrieval. Concept oriented views based on supper-concepts (metaterms) initially defined in CISMeF to optimize Web medical search, was implemented in our MRS as specialties views. This work shows that these terminological tools are able to facilitate information retrieval.

Evaluation of the ethanol intake on the Calomys callosus seminal vesicle structure

The effects of chronic alcohol ingestion on the structure of the glandular epithelium of the seminal vesicle of the rodent Calomys callosus were analyzed in 24 adult animals aged 3 months divided into three experimental groups. The control group received a solid diet and tap water, the alcoholic group received the same solid diet and ethanol P.A. diluted 20% in water (v/v) for 4 months. The abstinent group received the same liquid diet of the alcoholic one for the same period and after that the alcoholic diet was changed by water for a period of 3 months. After treatment, all animals were anesthetized, weighed and sacrificed. At the end of treatment, mean body weight did not differ between animal groups. The glandular epithelial cells of the alcoholic and abstinent groups showed atrophy and ultrastructural alterations such as the presence of altered nuclei, intense dilatation of the cisterns of the granular endoplasmic reticulum, intense digestive vacuoles and lipid droplets. Ethanol ingestion provokes marked lesions on the epithelium of the seminal vesicle probably interfering on the glandular secretion.

Morphological alterations on the prostate of Calomys callosus submitted to chronic ethanol ingestion

The objective of the present study was to assess the possible toxic effects of chronic alcohol ingestion on the ultrastructure of the glandular epithelium of the prostate of the rodent Calomys callosus, in order to contribute to the understanding of the consequences of alcohol abuse for the morphology of the male reproductive apparatus. Sixteen adult animals aged three months were divided into two experimental groups. The control group received a solid diet and tap water, and the alcoholic group received the same solid diet and ethanol P.A. diluted 20% in water (v/v). After 120 days of treatment, all animals were anesthetized, weighed and sacrificed. At the end of treatment, mean body weight did not differ between control and alcoholic animals. The prostate epithelial cells of the alcoholic group showed intense atrophy and ultrastructural alterations such as the presence of lipid droplets, altered nuclei, ruptured mitochondrial cristae, and intense dilatation of the cisterns of the granular endoplasmic reticulum. It was concluded that 20% ethanol provokes marked lesions on the epithelium of the prostate probably interfering on the glandular secretion.

Crohn's disease: increased mortality 10 years after diagnosis in a Europe-wide population based cohort

BACKGROUND

No previous correlation between phenotype at diagnosis of Crohn's disease (CD) and mortality has been performed. We assessed the predictive value of phenotype at diagnosis on overall and disease related mortality in a European cohort of CD patients.

METHODS

Overall and disease related mortality were recorded 10 years after diagnosis in a prospectively assembled, uniformly diagnosed European population based inception cohort of 380 CD patients diagnosed between 1991 and 1993. Standardised mortality ratios (SMRs) were calculated for geographic and phenotypic subgroups at diagnosis.

RESULTS

Thirty seven deaths were observed in the entire cohort whereas 21.5 deaths were expected (SMR 1.85 (95% CI 1.30-2.55)). Mortality risk was significantly increased in both females (SMR 1.93 (95% CI 1.10-3.14)) and males (SMR 1.79 (95% CI 1.11-2.73)). Patients from northern European centres had a significant overall increased mortality risk (SMR 2.04 (95% CI 1.32-3.01)) whereas a tendency towards increased overall mortality risk was also observed in the south (SMR 1.55 (95% CI 0.80-2.70)). Mortality risk was increased in patients with colonic disease location and with inflammatory disease behaviour at diagnosis. Mortality risk was also increased in the age group above 40 years at diagnosis for both total and CD related causes. Excess mortality was mainly due to gastrointestinal causes that were related to CD.

CONCLUSIONS

This European multinational population based study revealed an increased overall mortality risk in CD patients 10 years after diagnosis, and age above 40 years at diagnosis was found to be the sole factor associated with increased mortality risk.

Repercussions of castration and vasectomy on the ductal system of the rat ventral prostate

Diseases, such as cancer and benign prostatic hyperplasia, are related to disruption of the mechanism regulating the balance between cell proliferation and apoptosis in prostatic cells. Since castration and vasectomy might alter that balance, this study evaluates the cell proliferation, apoptosis and height of the secretory epithelium of the ventral-prostate ductal system post-castration and vasectomy. Immunohistochemical (PCNA and Ki67), cytochemical (Fuelgen reaction) and morphometric investigation have been carried out. Cell proliferation indices decreased significantly in both regions of the ventral-prostate ductal system after castration compared to the sham-operated group. The apoptotic index increased significantly after 48 h, declining 7 days post-castration. The cell proliferation indices did not differ after 48 h significantly; however, they increased 7 days post-vasectomy in both regions. The apoptotic index did not differ significantly in either time post-vasectomy. Castration caused an imbalance in favor of apoptosis, whereas vasectomy caused an imbalance in favor of cell proliferation.

Organ-specific distribution and subcellular localisation of ascorbate peroxidase isoenzymes in potato (Solanum tuberosum L.) plants

Ascorbate peroxidase (EC 1.11.1.11), a heme-containing homodimeric protein, is a hydrogen peroxide-scavenging enzyme, playing an important role in plants in order to protect them from oxidative stress, thus adverting cellular damage. Several ascorbate peroxidase isoenzymes have been reported but the understanding of their physiological role still depends on a better knowledge of their precise localisation within plant organs. Immunocytochemistry techniques were performed in order to elucidate the peroxisomal and cytosolic ascorbate peroxidase distribution within tissues of leaves and sprouts of potato plants. The peroxisomal isoenzyme was found to have a broad distribution in sprouts, but a differential one in leaves, being restricted to the spongy parenchyma. This differential expression may be associated to the mesophyll asymmetry and the diverse physiological processes that occur in it. The cytosolic isoenzyme was not detected in leaves under the used conditions, probably because it is present in low amounts in these tissues. The results obtained in sprouts were at least curious: cytosolic ascorbate was found to be adjacent to the amyloplasts. Given these results, it is possible to state that apart from their similarity, these two isoenzymes reside in different organelles and seem to take part in different physiological processes as suggested by their organ- and tissue-specific distribution.

Analysis of the dinucleotide repeat polymorphism in the epidermal growth factor receptor (EGFR) gene in head and neck cancer patients

BACKGROUND

Epidermal growth factor receptor (EGFR) overexpression is associated with poor prognosis in head and neck cancer. The first intron of EGFR gene is polymorphic (9-23 CA repeats) and transcription declines when the number of repeats increases.

PATIENTS AND METHODS

EGFR polymorphism (fluorescent genotyping) and expression (ligand-binding assay) were analyzed in tumors and normal tissues from 112 patients (100 men, 12 women; mean age 60 years).

RESULTS

The number of CA repeats varied from 15 to 22. Allelic distribution was trimodal (predominance of 16, 20 and 18 CA repeats). EGFR concentrations were significantly higher (P=0.02) in homozygous tumors as compared with heterozygous. Considering homozygous tumors, or classifying genotypes as short/long/intermediary (two alleles <17 versus two alleles > or =17 versus others), no relationship was observed between tumoral EGFR genotype and expression. In the 76 tumors exhibiting at least one 16-CA allele, the length of the remaining allele was inversely correlated to EGFR expression (P=0.047). Tumoral EGFR expression, performance status (WHO criteria) and node involvement were independent predictors of specific survival (P <0.01). Tumoral or normal tissue EGFR genotype did not influence survival.

CONCLUSIONS

Intron 1 EGFR polymorphism may be implicated in the regulation of EGFR expression in head and neck tumors.

Calculation of the vectorial field distribution in a stratified focal region of a high numerical aperture imaging system

We present an algorithm for calculating the field distribution in the focal region of stratified media which is fast and easy to implement. Using this algorithm we study the effect on the electric field distribution of an air gap separating a solid immersion lens and a sample, where we analyse the maximum distance for out-of-contact operation. Also, we study how the presence of a metallic substrate affects the field distribution in the focal region; the interference effects of the reflected field could be used as an alternative for 4Pi-microscopy.

Cylindrical vector beam focusing through a dielectric interface: comment

Errors in the results and conclusions presented in the paper "Cylindrical vector beam focusing through a dielectric interface" by Biss and Brown (Opt. Express 9, 490-497 (2001)) are discussed.

Neovascularisation is a prognostic factor of early recurrence in T1/G2 urothelial bladder tumours

BACKGROUND

Of patients with superficial bladder cancer, a group are still at risk of disease recurrence, progression and death from their cancer after curative treatment. Angiogenesis is a crucial pathogenic mechanism for this type of urothelial cell carcinoma (UCC), and is a potential therapeutic target. However, the selection of the appropriate patients remains a dilemma.

PATIENTS AND METHODS

Vascular endothelial growth factor (VEGF) expression and the presence of angiogenesis and occurrence of CD31, CD34, endoglin and factor VIII immunoexpression, were evaluated in 66 superficial papillary UCCs of the bladder and were correlated with classical histopathological factors and disease outcome.

RESULTS

VEGF immunoreactivity was observed in 100% of cases, and more intensely in the luminal surface. The presence of microvessel clusters independently of a fibrovascular core was observed in 22.7% of cases. Of these, the T1/G2 subgroup had an independent and significantly lower recurrence-free survival (P = 0.0002).

CONCLUSIONS

These results indicate that the presence of angiogenesis in tumour urothelium is a potential prognostic factor in superficial UCC, particularly in T1/G2 tumours, and may be used to select patients for anti-angiogenic treatments.

PIP2 binding residues of Kir2.1 are common targets of mutations causing Andersen syndrome

BACKGROUND

Mutations in KCNJ2, the gene encoding the inward-rectifying K+ channel Kir2.1, cause the cardiac, skeletal muscle, and developmental phenotypes of Andersen-Tawil syndrome (ATS; also known as Andersen syndrome). Although pathogenic mechanisms have been proposed for select mutations, a common mechanism has not been identified.

METHODS

Seventeen probands presenting with symptoms characteristic of ATS were evaluated clinically and screened for mutations in KCNJ2. The results of mutation analysis were combined with those from previously studied subjects to assess the frequency with which KCNJ2 mutations cause ATS.

RESULTS

Mutations in KCNJ2 were discovered in nine probands. These included six novel mutations (D71N, T75R, G146D, R189I, G300D, and R312C) as well as previously reported mutations R67W and R218W. Six probands possessed mutations of residues implicated in binding membrane-associated phosphatidylinositol 4,5-bisphosphate (PIP2). In total, mutations in PIP(2)-related residues accounted for disease in 18 of 29 (62%) reported KCNJ2 -based probands with ATS. Also reported is that mutation R67W causes the full clinical triad in two unrelated males.

CONCLUSIONS

The novel mutations corresponding to residues involved in Kir2.1 channel-PIP2 interactions presented here as well as the overall frequency of mutations occurring in these residues indicate that defects in PIP2 binding constitute a major pathogenic mechanism of ATS. Furthermore, screening KCNJ2 in patients with the complex phenotypes of ATS was found to be invaluable in establishing or confirming a disease diagnosis as mutations in this gene can be identified in the majority of patients.

Time evolution of the diffraction pattern of an ultrashort laser pulse

An analytical expression for the time evolution of the diffraction pattern of an ultrashort laser pulse passing through a circular aperture is obtained in the Fresnel regime. The diffraction is not constant in time as the pulse travels through the aperture. This may have implications in experiments involving fast dynamics. Examples of the evolution of the diffraction pattern are given.

The role of adherence in tuberculosis HIV-positive patients treated in ambulatory regimen

Adherence to antituberculosis treatment, a major determinant of outcome, is of special concern in human immunodeficiency virus (HIV)-positive patients. However, tuberculosis death in HIV-positive patients remains higher than in HIV-negative patients, regardless of adherence. To assess determinants for an unfavourable tuberculosis outcome (defined as no cure or death), and determinants for nonadherence to antituberculosis treatment, 70 HIV-positive patients with tuberculosis referred to an outpatient centre were studied. Patient outcome was compared according to HIV risk factors, other opportunistic diseases, antiretroviral drugs use, current i.v. drugs use, a methadone programme participation, tuberculosis features, treatment characteristics and adherence. Adherent and non-adherent patient characteristics were also compared. An unfavourable outcome occurred in 22.9% of patients and 32.9% were nonadherent with therapy. Nonadherence was the only independent determinant for an unfavourable outcome. Adherence was independently associated with current i.v. drug use, treatment complications and use of methadone. This study confirms that human immunodeficiency virus-infected patients, treated as outpatients, have high rates of nonadherence and that adherence is the strongest determinant for tuberculosis outcome. Independently of the current use of drugs, a methadone programme improves adherence to treatment.

[Human resources and the health system in Brazil]

This article discusses some questions related to human resources that act on Brazilian health system. At the beginning, it identifies the trends on health human resources in the last years. Then it shows on a brief discussion the health system reform, pointing out changes in the health model design through the implementation of the Family Health Program. This program tries to reorder the health care model, bringing the primary health care, in order to substitute the traditional model, designed to the cure of diseases and centered on hospitals. It also points out important changes on work conditions, such as: doctors' and dentists' no liberal work, low salaries, consultations paid by the HMO's, flexibilization of work, loss of work guarantees. Finally, it identifies serious problems in the Family Health Program, especially those related to the instability of work process and decreasing of social protection of workers who act on this program.

Identification of clinical staphylococcal isolates from humans by internal transcribed spacer PCR

The emergence of coagulase-negative staphylococci not only as human pathogens but also as reservoirs of antibiotic resistance determinants requires the deployment and development of methods for their rapid and reliable identification. Internal transcribed spacer-PCR (ITS-PCR) was used to identify a collection of 617 clinical staphylococcal isolates. The amplicons were resolved in high-resolution agarose gels and visually compared with the patterns obtained for the control strains of 29 staphylococcal species. Of the 617 isolates studied, 592 (95.95%) were identified by ITS-PCR and included 11 species: 302 isolates of Staphylococcus epidermidis, 157 of S. haemolyticus, 79 of S. aureus, 21 of S. hominis, 14 of S. saprophyticus, 8 of S. warneri, 6 of S. simulans, 2 of S. lugdunensis, and 1 each of S. caprae, S. carnosus, and S. cohnii. All species analyzed had unique ITS-PCR patterns, although some were very similar, namely, the group S. saprophyticus, S. cohnii, S. gallinarum, S. xylosus, S. lentus, S. equorum, and S. chromogenes, the pair S. schleiferi and S. vitulus, and the pair S. piscifermentans and S. carnosus. Four species, S. aureus, S. caprae, S. haemolyticus, and S. lugdunensis, showed polymorphisms on their ITS-PCR patterns. ITS-PCR proved to be a valuable alternative for the identification of staphylococci, offering, within the same response time and at lower cost, higher reliability than the currently available commercial systems.

Comparison of virologic, immunologic, and clinical response to five different initial protease inhibitor-containing and nevirapine-containing regimens

CONTEXT

The effectiveness of different protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors outside the setting of clinical trials has not been well described.

OBJECTIVES

To compare five different PI-and nevirapine (NVP)-containing regimens on virologic, immunologic, and clinical outcomes and treatment discontinuation.

DESIGN AND SETTING

Observational cohort study based on an HIV clinic in London.

PATIENTS

A total of 690 patients who received either saquinavir hard gel (SQV HG) (n = 183), indinavir (IDV) (n = 189), nelfinavir (NFV) (n = 109), ritonavir (RTV) (n = 42), ritonavir with saquinavir hard gel (RTV/SQV HG) (n = 45), or NVP (n = 122) as part of an initial PI-or NVP-containing treatment regimen between November 1994 and December 1998. A total of 351 (51%) patients had prior exposure to nucleoside reverse transcriptase inhibitors (NRTIs).

MAIN OUTCOME MEASURES

The main outcome measures were virologic undetectability, subsequent virologic rebound, CD4 cell count rise, development of AIDS, and treatment discontinuation. All analyses were stratified for year of initiation of the PI-or NVP-containing regimen.

RESULTS

Overall, 63% of patients attained an undetectable viral load (VL) within 6 months of starting their PI or NVP regimen. The adjusted relative hazard (95% confidence interval [CI]) for an undetectable VL relative to SQV HG was (in rank order): 2.77 (CI: 1.84-4.17) for NFV, 2.54 (CI: 1.81-3.57) for IDV, 2.43 (CI: 1.52-3.87) for RTV, 2.08 (CI: 1.28-3.37) for RTV/SQV HG, and 1.96 (CI: 1.35-2.85) for NVP. Forty-nine percent of patients experienced VL rebound within 12 months of initial attainment of undetectability, but relative to SQV HG, this did not differ significantly across the different PI and NVP regimens. The CD4 cell count response and rate of AIDS events were also similar across the different regimens. No independent predictors of VL undetectability were identified, but prior NRTI exposure was associated with VL rebound, and a lower baseline VL and CD4 cell count were associated with a reduced CD4 count response. The frequency (95% CI) of treatment discontinuation differed across the regimens; at 6 months, it was lowest for NFV (18% [CI: 13%-24%]), IDV (25% [CI: 22%-29%]), and NVP (28% [CI: 22%-34%]) and highest for RTV (41% [CI: 31%-52%]) and SQV HG (52% [CI: 48%-57%]).

CONCLUSIONS

Although PI- and NVP-containing regimens were similar in their CD4 cell count response and rates of subsequent VL rebound, differences were observed in time to VL undetectability and discontinuation rates relative to SQV HG. SQV HG was consistently inferior to the other PIs and NVP. The use of NFV and IDV was associated with the highest rates of undetectability, and together with NVP, the lowest rates of discontinuation.

Quantitation of cyclosporin A in whole blood by liquid chromatography/stable isotope dilution electrospray ionization mass spectrometry

Therapy with cyclosporin A (CsA) for immunosuppression after organ transplantation requires monitoring of its levels in blood owing to the narrow therapeutic index of the drug and to the high inter-individual variability of the drug absorption and metabolism. We describe the preparation of CsA labelled with stable isotopes ((13)C and (2)H) with an isotopic enrichment of about 99% using labelled glucose and its use as internal standard for quantification of CsA blood levels by isotope dilution/electrospray ionization mass spectrometry. The method was found to be linear in the tested range (1-1000 ng) with and without the matrix. The accuracy of the bracketting calibration curves prepared using 100 ng ml(-1) labelled CsA was within +/-1.7% (bias). The results confirmed the usefulness of the procedure as a reference method for the external quality assessment of the field methods for the evaluation of CsA blood concentration, the imprecision (relative standard deviation) and accuracy (bias) being <2%.

Appropriateness of emergency department visits in a Portuguese university hospital

STUDY OBJECTIVE

There are no studies in Portugal supporting a common claim that most emergency department visits are inappropriate. The aim of this study was to determine the prevalence of and to evaluate factors associated with an appropriate ED visit in a major public hospital.

METHODS

A cross-sectional prospective study was performed at a public university hospital ED. Data for demographic variables, duration of complaint, transfer from other medical sources, and previous medical care for the same complaints were collected by interviewing all patients who arrived at the ED within a consecutive period of at least 24 hours. Data for diagnostic tests, treatment performed, and final patient destination were collected by triage records review. An appropriate ED visit was defined by explicit criteria: interhospital transfer, patient death at the ED, hospitalization, and diagnostic tests or treatments performed.

RESULTS

The study included 5,818 adult patients. The prevalence of an appropriate ED visit, by use of our criteria, was 68.7%. Sex was an effect modifier. According to this study, determinants of an appropriate visit for men and women were age 60 years or older and complaints of 24 hours or less and in women but not in men, retired from work and with arrival between midnight and 8 AM.

CONCLUSIONS

In a university hospital in Oporto, the majority of ED visits were appropriate according to explicit criteria. Some variables may be associated with appropriateness of ED visits. A duration of the complaint 24 hours or less along with an arrival between midnight and 8 AM in women and age 60 years or older in men were the most important determinants.