Luteal progesterone relates to histological endometrial maturation in fertile women

To examine the relationship between endometrial histological maturation and reproductive hormones, we studied 11 fertile women, aged 18-37 yr. All participants had had at least 1 previous pregnancy and cycled regularly, every 25-35 days. Women collected daily, first morning voided urine for measurement of estradiol and progesterone metabolite excretion, estrone conjugates (E1c), and pregnanediol glucuronide (Pdg), respectively, throughout the cycle of study. Hormones were normalized for creatinine. Between 7-9 days after home detection of a LH surge (Sure Step), participants underwent an endometrial biopsy using a small bore (Pipelle) catheter. Tissue was prepared for histological and biochemical analyses. The histological analysis is reported herein. Endometrium was dated by 3 authors (N.S., D.H., and S.P.), all of whom were blinded to the participant's identity or timing of biopsy within her cycle. Final dating was agreed upon based upon the method of Noyes et al. E1c and Pdg were integrated throughout the cycle using the trapezoidal rule, and correlations were sought between deviation from expected histology (based upon urinary hormones and LH surge) and integrated hormone values. E1c varied over a 2-fold range in these normal women, from 1196-2040 ng/cycle. Pdg excretion was much more variable, ranging from 22-119 microg/cycle. No relationship could be found between histological lagging of endometrial maturation and lower excretion of E1c. A moderate correlation was observed (Spearman's r = 0.6; P < 0.05) between degree of histological maturation and integrated Pdg. Of two women with evidence of a disparity between gland and stromal development (glands lagging behind stroma by >2 days), one excreted 24 microg Pdg/cycle, the next to lowest value. We conclude that normal fertile women experience a wide range of hormone concentrations in the face of normal endometrial maturation. Progesterone appears to exert a dose-related effect on endometrial maturation, and the techniques we used, although relatively crude clinical measures, appeared to be sufficient to detect this relationship.

Mitral papillary fibroelastoma as a cause of cardiogenic embolic stroke: report of two cases and review of the literature

Papillary fibroelastoma (PFE) is a rare benign tumour that attaches to the endocardial surface, mostly on cardiac valves. Though usually asymptomatic, it can be the source of several complications. To date, 49 cases have been reported of embolic stroke with a PFE as the probable origin.

CASE REPORTS

(i) a 39-year-old male presented with ischemic embolic stroke; the presence of a PFE was assessed by means of transoesophageal echocardiography and confirmed by pathological findings; (ii) a 32-year-old woman presented with sudden onset of left hemiparesis; a cardiogenic embolic stroke was suspected, and a diagnosis of PFE was made based on echocardiographic and pathological findings. In both cases, surgical excision of the tumours was performed with no recurrences at follow-up. Two mechanisms can explain the formation of emboli in PFE: dislodgement of the tumour leaves or fibrin-platelet aggregation on the endocardial surface of these leaves. Transthoracic echocardiography may lead to the suspicion of a PFE, but transoesophageal echocardiography is required for confirmation. Prompt surgical excision is indicated in most cases. Anticoagulation is only recommended in situations of high surgical risk and during the wait for surgery.

[Diffusion-weighted magnetic resonance in the diagnosis of acute subcortical infarcts]

INTRODUCTION

The diagnostic efficacy of radiological studies in acute subcortical infarcts is limited by the low sensitivity of conventional computerized tomography (CT) and magnetic resonance (MR) in detecting small-sized infarcts, and the difficulty in differentiating acute from chronic lesions. Diffusion-weighted MR (DMR) has shown great sensitivity and specificity in the detection of small vessel ischemic lesions during the acute phase.

OBJECTIVE

To determine the diagnostic value of DMR in the study of patients with subcortical infarcts during the acute phase.

PATIENTS AND METHODS

We made a prospective analysis of 100 consecutive patients with a clinical diagnosis of subcortical infarct. In all cases MR examination was done within the first 10 days (average 3.9 days) following onset, using conventional and diffusion-weighted sequences.

RESULTS

In all cases the DMR showed the presence of ischemic lesions which explained, at least partly, the clinical features of the stroke. In 42 patients (42%) the DMR gave relevant information for diagnosis, as compared with the conventional MR studies, by confirming the presence of an ischemic lesion responsible for the clinical picture. The percentage rose to 50% when the examination was done within the first two days.

CONCLUSIONS

DMR gives useful information in a high percentage of patients with acute subcortical infarcts. This is due to its great sensitivity in the detection of acute lesions of small size, and capacity to distinguish acute from chronic lesions.

[Lack of correlation between plasma homocysteine levels and cerebral microangiopathy in patients wtih transient ischemic attack]

OBJECTIVE

The aim of this study is to evaluate cerebral MRI findings in patients with atherothrombotic transient ischemic attacks (TIA) and its correlation with plasma homocysteine (Hcy) levels.

PATIENTS AND METHODS

A total of 62 consecutive patients with the diagnosis of TIA of atherothrombotic origin were studied. MRI examinations were performed in all patients for the evaluation of the presence of infarct and/or white matter hyperintensities (WMHI). Plasma Hcy levels were determined according to the method described by Smolin and Schneider modified.

RESULTS

Plasma Hcy levels were significantly (p < 0.036) higher in patients with MRI-detected infarcts (9.69 +/- 2.06 mumol/l) compared with patients without infarcts (8.65 +/- 1.7 mumol/l. There was no correlation (p < 0.33) between plasma Hcy levels and the presence or absence of WMHI seen on MRI.

CONCLUSIONS

In TIA patients, plasma Hcy levels were significantly higher in patients with cerebral infarcts, but did not correlate with the presence of WMHI. Our results suggest that mild hyperhomocysteinemia would be associated with large-medium vessel rather than with small vessel disease.

[Consumption of licit and illicit drugs in Chile: results of the 1998 study and comparison with the 1994 and 1996 studies]

The principal results are presented here from the Third National Study of the Consumption of Drugs, which was carried out in Chile by the National Board for Narcotics Control between 1 September 1998 and 15 January 1999. The 1998 study used the same methodological design as the first and second studies, which were done in 1994 and 1996. The 1998 study expanded the sample to 31,665 individuals, who were representative of a population of 6,940,727 people from 12 to 64 years old, both sexes, and five socioeconomic levels and who were residents of urban areas in 62 commune administrative divisions of the 13 regions of the country. Results from the 1998 study are compared with those from 1996 and 1994. The 1998 study shows that 17.5% of Chileans have at some time in their life used one of the three illicit drugs most popular in the country: marijuana (16.8%), coca paste (2.3%), and cocaine hydrochloride (4.0%). The prevalence of use of any of the three drugs, mainly marijuana, during the preceding year was 5.3% and during the preceding month 2.2%. With respect to licit drugs, 28.4% of Chileans have at some time in their lives used antianxiety drugs, 84.4% of them have consumed alcohol, and 71.9% have used tobacco. Most of the people who once used illegal drugs have stopped doing so: 71.6% in the case of marijuana, 64.1% with coca paste, and 66.8% with cocaine hydrochloride. For legal drugs, the percentages were lower: 55.5% for anxiolytics, 16.0% for alcohol, and 34.5% for tobacco. The consumption of licit and illicit drugs was several times greater among men than among women, except for anxiolytics, whose use was three times greater among women. Drug use was more frequent among persons between 19 and 25 years old. Consumption of illegal drugs was more frequent at higher socioeconomic levels, and use of licit drugs was more common in the lower socioeconomic levels. The 50th percentile of the age of initiating drug use was 17 years for alcohol, 15 for tobacco, 30 for antianxiety agents, 17 for marijuana, 20 for coca paste, and 21 for cocaine hydrochloride. Comparing the results of the three studies shows that, after an increase in the use of licit drugs between 1994 and 1996, there was a stabilization in 1998. With illegal drugs there was a modest increase in consumption between 1996 and 1998, following a small reduction between 1994 and 1996.

'Herald hemiparesis' of basilar artery occlusion: early recognition by transcranial Doppler ultrasound

A transient hemiparesis may be ocassionally present at an early stage of the thrombosis of the basilar artery (herald hemiparesis). We report on one of these cases and the valuable role of transcranial Doppler ultrasound (TCD) to the early detection of the stroke-in-evolution. TCD in the emergency room is a good tool to assess a basilar occlusion, searching for direct (absence of signal at the basilar artery) and indirect (reversal flow of the pre-communicating segment the of posterior cerebral artery through the posterior communicating artery) signs. Early recognition and treatment of this condition could avoid the development of the full syndrome of the basilar artery thrombosis.

[Acute pseudobulbar paralysis: the use of diffusion techniques with magnetic resonance]

INTRODUCTION

Acute pseudobulbar palsy produced by bilateral cerebral infarctions is a rare syndrome, which includes among its symptoms mutism, severe dysphagia and diverse sensory-motor signs.

CLINICAL CASES

We report two middle-aged patients who suddenly developed a severe dysarthria and dysphagia, which impeded their ability to speak and to feed themselves, with spasmodic laughing and crying and slight motor deficit ('pure' pseudobulbar palsy). The acute lesions, using conventional and diffusion-weighted magnetic resonance imaging, corresponded partially to the anterior choroidal artery (case 1: acute lesion in the left periventricular white matter and a subacute one in the right semioval centrum; case 2: acute lesions in the right frontal subcortical white matter and in the periventricular white matter adjacent to the left lateral ventricle). The favorable evolution of these patients in contrast to previously described patients with acute pseudobulbar palsy could indicate that the motor deficit is a prognostic factor for this syndrome.

CONCLUSIONS

Diffusion-Weighted magnetic resonance imaging permits differentiation with high precision of the acute lesions in patients who present old ones. Sometimes multiple acute lacunar infarctions (MALI) are found to be responsible of the syndrome. Hypertension and diabetes are the risk factors for the small vessel disease underlying these MALI.

Transcriptional up-regulation of the cyclin D2 gene and acquisition of new cyclin-dependent kinase partners in human T-cell leukemia virus type 1-infected cells

Human T-cell leukemia virus type 1 (HTLV-1) is the etiologic agent for adult T-cell leukemia/lymphoma (ATL) and HTLV-1-associated myelopathy/tropical spastic paraparesis. Tax(1) is a 40-kDa phosphoprotein, predominantly localized in the nucleus of the host cell, which functions to transactivate both viral and cellular promoters. It seems likely that HTLV-1, through expression of the viral regulatory protein Tax(1), provides some initial alteration in cell metabolism predisposing the development of ATL. Here, we demonstrate that HTLV-1 infection in T-cell lines and patient samples causes overexpression of an early G(1) cyclin, cyclin D2. The transcriptional up-regulation of the cyclin D2 gene is due to activation of Tax on the cyclin D2 gene. More important, we find that overexpression of cyclin D2 is accompanied by acquisition of new partners such as cyclin-dependent kinase 2 (cdk2), cdk4, and cdk6 in infected cells. This is in contrast to uninfected T cells, where cyclin D2 associates only with cdk6. Functional effects of these cyclin-cdk complexes in infected cells are shown by hyperphosphorylation of Rb and histone H1, indicators of active progression into S phase as well as changes in cellular chromatin and transcription machinery. These studies link HTLV-1 infection with changes of cellular cyclin gene expression, hence providing clues to development of T-cell leukemia.

[Determination of Doppler parameters in the study of basal cerebral veins: basal vein of Rosenthal and middle cerebral vein]

INTRODUCTION

To date, little attention has been paid to the study of the venous system by means of transcranial Doppler ultrasound. The objective of our study was to learn how to localize cerebral blood flow and find the normal values of different ultrasonographic parameters.

PATIENTS AND METHODS

We studied 20 healthy persons in whom the arterial system of the circle of Willis had previously been shown to be normal. Transcranial Doppler scan was done with the person lying face upwards, using a transtemporal 2 MHz catheter. In the study we included persons in whom at least one of the two veins could be studied unilaterally.

RESULTS

We studied twelve men and eight women aged between 25 and 78 years. The basal vein of Rosenthal, localized bilaterally in 70% of the cases, was identified as a wave of low pulsation between segments P1 and P2 of the posterior cerebral artery, going away from the catheter at a speed of about 11 cm/second. The middle cerebral vein was found bilaterally in only 35% of the cases as a wave near to the middle cerebral artery but in the opposite direction, at an average velocity of approximately 11.7 cm/second and of low pulsation.

CONCLUSIONS

In spite of the technical problems, which can be solved using contrast agents, it is possible to study the cerebral venous system by means of transcranial Doppler. Our Unit is the first in Spain to show this. We therefore wish to promote the use of transcranial Doppler in cerebral venous disorders.

Impaired cerebrovascular reactivity as a risk marker for first-ever lacunar infarction: A case-control study

BACKGROUND AND PURPOSE

Functional assessment of small arteries and arterioles could provide valuable information regarding the extent of diffuse arteriolosclerosis in patients with small-vessel disease. Therefore we attempted to clarify the role of cerebrovascular reactivity (CVR) as a risk marker for first-ever symptomatic lacunar infarction.

METHODS

Forty-six patients with lacunar infarction and 46 sex- and age-matched control subjects were prospectively evaluated. Cerebral hemodynamics were studied with transcranial Doppler ultrasonography. CVR was examined by calculating the percent increase in mean flow velocity occurring after 15 mg/kg acetazolamide administration (Diamox test).

RESULTS

CVR was significantly (P<0.0001, Student's t test) lower in cases (50.0+/-12. 7%) as compared with control subjects (65.2+/-12.4%). A multiple logistic regression analysis identified male sex (odds ratio [OR] 2. 3, P=0.02), age (OR 3.6, P<0.005), and the presence of lacunar infarction on magnetic resonance imaging (OR 5.3, P<0.001) as significant and independent factors associated with a reduction of CVR. Moreover, a cut-point of 55.6% (sensitivity 67%, specificity 82%) was established as the threshold value for distinguishing between pathological and normal CVR. CVR was significantly (P=0.02) lower in patients with multiple (46.38+/-12.6%) than with single (54. 83+/-11.58%) lacunar infarction. In addition, a trend of negative correlation was found between CVR and the number of lacunar infarctions (r=-0.26, P=0.08). In the multiple logistic model, history of hypertension (OR 7.24; 95% confidence interval 2.95 to 17. 79) and CVR (OR 0.8; 95% confidence interval 0.81 to 0.93) emerge as significant and independent predictors of first-ever lacunar infarction.

CONCLUSIONS

These data suggest that impaired CVR is a risk marker for first-ever lacunar infarction.

["Stroke code". Shortening the delay in reperfusion treatment of acute ischemic stroke]

BACKGROUND

"Stroke Code" is a system for the rapid identification, pre-notification and transport of acute ischemic stroke patients. The objective of this study was to evaluate the impact of delay reduction for thrombolytic therapy in these patients.

SUBJECTS AND METHODS

We evaluated acute ischemic stroke patients admitted in the emergency unit within the first 6 hours after onset of symptoms and included into reperfusion clinical trials. We compared the delay for initiating reperfusion treatment related to the activation or not of the stroke code.

RESULTS

From 454 patients evaluated, 25% were admitted to the hospital in less than 6 hours from stroke onset. 59% of these patients were candidates for reperfusion treatment. "Stroke Code" was activated in 13 (55%). We observed a significant reduction in the delay since the onset of symptoms in relation to "Stroke Code" activation or not (mean X [SD]): emergency room arrival: 49.6 (48) vs 80 (48) min; Stroke Team evaluation: 65.3 (57) vs 133.6 (58) min; CT scan performing: 86.2 (60) vs 171.8 (62) min; Start of treatment; 212.9 (51) vs 287.3 (59) min.

CONCLUSIONS

"Stroke Code" activation reduced in 50% pre- and in-hospital delay to start reperfusion treatment in acute ischemic stroke patients.

[Vertebrobasilar abnormalities in patients with hemifacial spasm: MR-angiography findings]

INTRODUCTION

Hemifacial spasm (HFS) is a disorder characterized by a complex of symptoms with hyperactive motor dysfunction of the facial nerve. It is indicated that HFS in the majority of cases can be caused by a blood vessel compressing the nerve adjacent to the brainstem.

PATIENTS AND METHODS

We studied and treated 44 patients with HFS. Magnetic resonance imaging (MR) and MR-angiography of the brain were performed in patients with HFS to asses the presence of an artery of the vertebrobasilar system compressing the root of the facial nerve. We evaluate the response to treatment with Botulinum toxin in these cases. 14 patients were excluded (6 patients presented HFS due to other lesions and in 8 patients the MR was not performed). The remaining 30 patients with idiopathic HFS underwent MR/MRA (3D-FISP) and it was also performed in 14 patients with synkineses after facial palsy to be used as controls.

RESULTS

The MRA documented an abnormal position of the arteries surrounding the facial nerve (ipsilaterally to HFS) in 22 patients. The compressing artery was the PICA in 3 patients (10%), the AICA in 3 patients, the vertebral artery in 7 patients and the basilar artery in 8 patients, one patient showed a combined compression by AICA and PICA. The remaining 8 patients had a normal MRI. At the control group only one patient presented an abnormal AICA and the other had a normal MRI-MRA. Patients were followed-up for 22.4 months and after Botulinum toxin treatment patients kept 4.81 months free of symptoms.

CONCLUSIONS

We recommend to perform MR studies in all HFS patients to rule out a secondary cause of the disease and MRA to evaluate the underlying vertebrobasilar abnormalities if surgery is planned. Botulinum toxin is a useful treatment in these patients and only after its failure, microvascular decompression will be considered.

[Stroke: a stranger among the people]

INTRODUCTION

Lack of awareness of warning signs of stroke is a factor that contribute to late patient arrival to the emergency department.

OBJECTIVE

The goal of this pilot study was to determine the baseline knowledge of stroke among the population (terminology, signs-symptoms, risk factors and attitude) prior to educational campaigns.

PATIENTS AND METHODS

A population-based interview using closed-ended questions was conducted by neurologists among 100 users of the Vall d'Hebron's Primary Health Center, randomly sampled.

RESULTS

In our population a 9% unknowns totally the disease, of the remainder, 42% has a good knowledge of signs-symptoms and 46% of risk factors. Only 22% of the sample has good global knowledge of the disease. If suffering a stroke this population should seek medical attention through 911 (46.2%) or come directly to the emergency department (50.5%). If symptoms were gone away, transient ischemic attack (TIA), appears a trend to contact primary physicians (59.3%). Respondents aged > 65 years were less likely to recognize symptoms (p = 0.001) and to consider stroke as an emergency. Respondents with an affected relative (50.5%) tend to locate more exactly the disease at the brain (p = 0.05) and to arrive earlier to the emergency department (p = 0.045), than those with non-affected relatives.

CONCLUSIONS

Less than a quarter of our population have a good knowledge of the disease. Stroke is considered an emergency unlike TIA. The information about stroke is theoretically associated with early presentation to the emergency department. These results permit a redesign of the questionnaire to conduct a second phase of the study and generalize them for the Spanish population.

[Presentation of the Environmental-Health Prize 1997: Lyme borreliosis]

Lyme borreliosis is an infectious disease, with multisystem involvement, due to a spirochete known as Borrelia burgdorferi, transmitted to humans by ticks; its recent emergence is, in part, the consequence of reforestation and the rise in deer and rodents populations. The prevention and the treatment of this disease are well standardized, the main risk being its misdiagnosis.

[Isolated axial lateral pulse as a sign of latero-bulbar ischemia: clinical topographic correlation]

INTRODUCTION

Isolated body lateropulsion in absence of vertigo, cerebellar syndrome, sensory loss or motor weakness is an extremely rare. This condition has only been reported four times.

CLINICAL CASES AND CONCLUSION

We present four patients in whom isolated body lateropulsion was a single manifestation of lateral medullary ischemia.

Ectopic ICER expression in pituitary corticotroph AtT20 cells: effects on morphology, cell cycle, and hormonal production

The products of the cAMP response element modulator (CREM) gene play an important role in the transcriptional response to cAMP in endocrine cells. By virtue of an alternative, intronic promoter within the gene, the inducible cAMP early repressor (ICER) isoform is generated. ICER was shown to act as a dominant negative regulator and to be cAMP-inducible in various neuroendocrine cells and tissues. ICER negatively autoregulates its own expression and has been postulated to participate in the molecular events governing oscillatory hormonal regulations. To elucidate ICER function in pituitary physiology, we have generated AtT20 corticotroph cell lines expressing the sense or antisense ICER transcript under the control of the cadmium-inducible human methallothionein IIA promoter. Here we demonstrate that changes in the regulated levels of ICER have drastic consequences on the physiology of the corticotrophs. Ectopic ICER expression induces remarkable modifications in AtT20 morphology. Cells with persistent, nonregulated high levels of ICER are blocked in the G2/M phase of the cell cycle, while the opposite effect is obtained in cells expressing an antisense ICER transcript. We show that the effect of ICER on the AtT20 cell cycle is correlated to a direct down-regulation of the cyclin A gene promoter by ICER. Finally, we show that ACTH hormonal secretion from the corticotrophs is completely blocked by ICER ectopic expression. Interestingly, this effect is not due to a direct regulation of the POMC gene, but is mediated by a transcriptional control of the prohormone convertase 1 gene. These results point to a key regulatory function of CREM in pituitary physiology.