Non-scarring alopecia of lupus erythematosus: A comprehensive review

BACKGROUND

Although non-scarring alopecia (NSA) is a frequent clinical finding in patients with systemic lupus erythematosus (SLE), it has been poorly described in the literature. It is considered a nonspecific sign in the current classification of skin lesions of LE. The aim of this study was to give an updated overview of the spectrum of NSA in LE patients, with emphasis on the clinical significance thereof.

METHOD

We conducted a review of the English literature using the PubMed-Medline database using the keywords "Alopecia" + "Lupus erythematosus". Publications describing LE patients with NSA were included.

RESULTS

Data for 237 patients from 27 publications were analyzed. Ninety-one patients had diffuse NSA, 43 had patchy NSA, 83 had lupus hair, 3 had alopecia of dermal cutaneous LE, and 17 had alopecia of linear and annular lupus panniculitis of the scalp. Patients with diffuse/patchy NSA and lupus hair shared the following features: strong association with systemic activity of LE, subtle clinical/trichoscopic signs of inflammation, histological aspect consistent with lesions specific to cutaneous LE, high likelihood of response to SLE therapy, and absence of progression to scarring alopecia. Association with SLE was rare in patients with dermal cutaneous LE or linear and annular lupus panniculitis of the scalp, and skin-directed therapies were most often effective. One patient of each subtype progressed to scarring alopecia.

DISCUSSION

Diffuse/patchy NSA and lupus hair may represent a topographic variation of a single entity specific for LE. Prospective studies are warranted to further document the clinical significance of this manifestation.

Report on G4-Med, a Geant4 benchmarking system for medical physics applications developed by the Geant4 Medical Simulation Benchmarking Group

BACKGROUND

Geant4 is a Monte Carlo code extensively used in medical physics for a wide range of applications, such as dosimetry, micro- and nanodosimetry, imaging, radiation protection, and nuclear medicine. Geant4 is continuously evolving, so it is crucial to have a system that benchmarks this Monte Carlo code for medical physics against reference data and to perform regression testing.

AIMS

To respond to these needs, we developed G4-Med, a benchmarking and regression testing system of Geant4 for medical physics.

MATERIALS AND METHODS

G4-Med currently includes 18 tests. They range from the benchmarking of fundamental physics quantities to the testing of Monte Carlo simulation setups typical of medical physics applications. Both electromagnetic and hadronic physics processes and models within the prebuilt Geant4 physics lists are tested. The tests included in G4-Med are executed on the CERN computing infrastructure via the use of the geant-val web application, developed at CERN for Geant4 testing. The physical observables can be compared to reference data for benchmarking and to results of previous Geant4 versions for regression testing purposes.

RESULTS

This paper describes the tests included in G4-Med and shows the results derived from the benchmarking of Geant4 10.5 against reference data.

DISCUSSION

Our results indicate that the Geant4 electromagnetic physics constructor G4EmStandardPhysics_option4 gives a good agreement with the reference data for all the tests. The QGSP_BIC_HP physics list provided an overall adequate description of the physics involved in hadron therapy, including proton and carbon ion therapy. New tests should be included in the next stage of the project to extend the benchmarking to other physical quantities and application scenarios of interest for medical physics.

CONCLUSION

The results presented and discussed in this paper will aid users in tailoring physics lists to their particular application.

Electrohysterogram for ANN-Based Prediction of Imminent Labor in Women with Threatened Preterm Labor Undergoing Tocolytic Therapy

Threatened preterm labor (TPL) is the most common cause of hospitalization in the second half of pregnancy and entails high costs for health systems. Currently, no reliable labor proximity prediction techniques are available for clinical use. Regular checks by uterine electrohysterogram (EHG) for predicting preterm labor have been widely studied. The aim of the present study was to assess the feasibility of predicting labor with a 7- and 14-day time horizon in TPL women, who may be under tocolytic treatment, using EHG and/or obstetric data. Based on 140 EHG recordings, artificial neural networks were used to develop prediction models. Non-linear EHG parameters were found to be more reliable than linear for differentiating labor in under and over 7/14 days. Using EHG and obstetric data, the <7- and <14-day labor prediction models achieved an AUC in the test group of 87.1 ± 4.3% and 76.2 ± 5.8%, respectively. These results suggest that EHG can be reliable for predicting imminent labor in TPL women, regardless of the tocolytic therapy stage. This paves the way for the development of diagnostic tools to help obstetricians make better decisions on treatments, hospital stays and admitting TPL women, and can therefore reduce costs and improve maternal and fetal wellbeing.

Impact of age on the use of adjuvant treatments in patients undergoing surgery for colorectal cancer: patients with stage III colon or stage II/III rectal cancer

Background

Many older patients don’t receive appropriate oncological treatment. Our aim was to analyse whether there are age differences in the use of adjuvant chemotherapy and preoperative radiotherapy in patients with colorectal cancer.

Methods

A prospective cohort study was conducted in 22 hospitals including 1157 patients with stage III colon or stage II/III rectal cancer who underwent surgery. Primary outcomes were the use of adjuvant chemotherapy for stage III colon cancer and preoperative radiotherapy for stage II/III rectal cancer. Generalised estimating equations were used to adjust for education, living arrangements, area deprivation, comorbidity and clinical tumour characteristics.

Results

In colon cancer 92% of patients aged under 65 years, 77% of those aged 65 to 80 years and 27% of those aged over 80 years received adjuvant chemotherapy (χ²_trends < 0.001). In rectal cancer preoperative radiotherapy was used in 68% of patients aged under 65 years, 60% of those aged 65 to 80 years, and 42% of those aged over 80 years (χ²_trends < 0.001). Adjusting by comorbidity level, tumour characteristics and socioeconomic level, the odds ratio of use of chemotherapy compared with those under age 65, was 0.3 (0.1–0.6) and 0.04 (0.02–0.09) for those aged 65 to 80 and those aged over 80, respectively; similarly, the odds ratio of use of preoperative radiotherapy was 0.9 (0.6–1.4) and 0.5 (0.3–0.8) compared with those under 65 years of age.

Conclusions

The probability of older patients with colorectal cancer receiving adjuvant chemotherapy and preoperative radiotherapy is lower than that of younger patients; many of them are not receiving the treatments recommended by clinical practice guidelines. Differences in comorbidity, tumour characteristics, curative resection, and socioeconomic factors do not explain this lower probability of treatment. Research is needed to identify the role of physical and cognitive functional status, doctors’ attitudes, and preferences of patients and their relatives, in the use of adjuvant therapies.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5910-z) contains supplementary material, which is available to authorized users.

Electrohysterography in the diagnosis of preterm birth: a review

Preterm birth (PTB) is one of the most common and serious complications in pregnancy. About 15 million preterm neonates are born every year, with ratios of 10-15% of total births. In industrialized countries, preterm delivery is responsible for 70% of mortality and 75% of morbidity in the neonatal period. Diagnostic means for its timely risk assessment are lacking and the underlying physiological mechanisms are unclear. Surface recording of the uterine myoelectrical activity (electrohysterogram, EHG) has emerged as a better uterine dynamics monitoring technique than traditional surface pressure recordings and provides information on the condition of uterine muscle in different obstetrical scenarios with emphasis on predicting preterm deliveries.

OBJECTIVE

A comprehensive review of the literature was performed on studies related to the use of the electrohysterogram in the PTB context.

APPROACH

This review presents and discusses the results according to the different types of parameter (temporal and spectral, non-linear and bivariate) used for EHG characterization.

MAIN RESULTS

Electrohysterogram analysis reveals that the uterine electrophysiological changes that precede spontaneous preterm labor are associated with contractions of more intensity, higher frequency content, faster and more organized propagated activity and stronger coupling of different uterine areas. Temporal, spectral, non-linear and bivariate EHG analyses therefore provide useful and complementary information. Classificatory techniques of different types and varying complexity have been developed to diagnose PTB. The information derived from these different types of EHG parameters, either individually or in combination, is able to provide more accurate predictions of PTB than current clinical methods. However, in order to extend EHG to clinical applications, the recording set-up should be simplified, be less intrusive and more robust-and signal analysis should be automated without requiring much supervision and yield physiologically interpretable results.

SIGNIFICANCE

This review provides a general background to PTB and describes how EHG can be used to better understand its underlying physiological mechanisms and improve its prediction. The findings will help future research workers to decide the most appropriate EHG features to be used in their analyses and facilitate future clinical EHG applications in order to improve PTB prediction.

sFlt-1/PlGF for prediction of early-onset pre-eclampsia: STEPS (Study of Early Pre-eclampsia in Spain)

OBJECTIVE

A high ratio of soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) has been linked to pre-eclampsia (PE). We evaluated the sFlt-1/PlGF ratio as a predictive marker for early-onset PE in women at risk of PE.

METHODS

This prospective, Spanish, multicenter study included pregnant women with a risk factor for PE, including intrauterine growth restriction, PE, eclampsia or hemolysis, elevated liver enzymes and low platelet count syndrome in previous pregnancy, pregestational diabetes or abnormal uterine artery Doppler. The primary objective was to show that the sFlt-1/PlGF ratio at 20, 24 and 28 weeks' gestation was predictive of early-onset PE (< 34 + 0 weeks). Serum sFlt-1 and PlGF were measured at 20, 24 and 28 weeks. Multivariate logistic regression was used to develop a predictive model.

RESULTS

A total of 819 women were enrolled, of which 729 were suitable for analysis. Of these, 78 (10.7%) women developed PE (24 early onset and 54 late onset). Median sFlt-1/PlGF ratio at 20, 24 and 28 weeks was 6.3 (interquartile range (IQR), 4.1-9.3), 4.0 (IQR, 2.6-6.3) and 3.3 (IQR, 2.0-5.9), respectively, for women who did not develop PE (controls); 14.5 (IQR, 5.5-43.7), 18.4 (IQR, 8.2-57.9) and 51.9 (IQR, 11.5-145.6) for women with early-onset PE; and 6.7 (IQR, 4.6-9.9), 4.7 (IQR, 2.8-7.2) and 6.0 (IQR, 3.8-10.5) for women with late-onset PE. Compared with early-onset PE, the sFlt-1/PlGF ratio was significantly lower in controls (P < 0.001 at each timepoint) and in women with chronic hypertension (P < 0.001 at each timepoint), gestational hypertension (P < 0.001 at each timepoint) and late-onset PE (P < 0.001 at each timepoint). A prediction model for early-onset PE was developed, which included the sFlt-1/PlGF ratio plus mean arterial pressure, being parous and previous PE, with areas under the receiver-operating characteristics curves of 0.86 (95% CI, 0.77-0.95), 0.91 (95% CI, 0.85-0.97) and 0.93 (95% CI, 0.86-0.99) at 20, 24 and 28 weeks, respectively, and was superior to models using the sFlt-1/PlGF ratio alone or uterine artery mean pulsatility index.

CONCLUSIONS

The sFlt-1/PlGF ratio can improve prediction of early-onset PE for women at risk of this condition. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Vaginal progesterone decreases preterm birth and neonatal morbidity and mortality in women with a twin gestation and a short cervix: an updated meta-analysis of individual patient data

OBJECTIVE

To assess the efficacy of vaginal progesterone for the prevention of preterm birth and neonatal morbidity and mortality in asymptomatic women with a twin gestation and a sonographic short cervix (cervical length ≤ 25 mm) in the mid-trimester.

METHODS

This was an updated systematic review and meta-analysis of individual patient data (IPD) from randomized controlled trials comparing vaginal progesterone with placebo/no treatment in women with a twin gestation and a mid-trimester sonographic cervical length ≤ 25 mm. MEDLINE, EMBASE, POPLINE, CINAHL and LILACS (all from inception to 31 December 2016), the Cochrane Central Register of Controlled Trials, Research Registers of ongoing trials, Google Scholar, conference proceedings and reference lists of identified studies were searched. The primary outcome measure was preterm birth < 33 weeks' gestation. Two reviewers independently selected studies, assessed the risk of bias and extracted the data. Pooled relative risks (RRs) with 95% confidence intervals (CI) were calculated.

RESULTS

IPD were available for 303 women (159 assigned to vaginal progesterone and 144 assigned to placebo/no treatment) and their 606 fetuses/infants from six randomized controlled trials. One study, which included women with a cervical length between 20 and 25 mm, provided 74% of the total sample size of the IPD meta-analysis. Vaginal progesterone, compared with placebo/no treatment, was associated with a statistically significant reduction in the risk of preterm birth < 33 weeks' gestation (31.4% vs 43.1%; RR, 0.69 (95% CI, 0.51-0.93); moderate-quality evidence). Moreover, vaginal progesterone administration was associated with a significant decrease in the risk of preterm birth < 35, < 34, < 32 and < 30 weeks' gestation (RRs ranging from 0.47 to 0.83), neonatal death (RR, 0.53 (95% CI, 0.35-0.81)), respiratory distress syndrome (RR, 0.70 (95% CI, 0.56-0.89)), composite neonatal morbidity and mortality (RR, 0.61 (95% CI, 0.34-0.98)), use of mechanical ventilation (RR, 0.54 (95% CI, 0.36-0.81)) and birth weight < 1500 g (RR, 0.53 (95% CI, 0.35-0.80)) (all moderate-quality evidence). There were no significant differences in neurodevelopmental outcomes at 4-5 years of age between the vaginal progesterone and placebo groups.

CONCLUSION

Administration of vaginal progesterone to asymptomatic women with a twin gestation and a sonographic short cervix in the mid-trimester reduces the risk of preterm birth occurring at < 30 to < 35 gestational weeks, neonatal mortality and some measures of neonatal morbidity, without any demonstrable deleterious effects on childhood neurodevelopment. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Unusual twin pregnancy: complete hydatidiform mole with coexistent normal fetus

The authors present a case of complete hydatidiform mole and coexisting fetus (CHMCF) in which mole gestation caused a placenta previa; with a posterior preterm premature rupture of membranes (PPROM) and ending in the 28h week of gestation due to acute chorioamnionitis, obtaining a live preterm newborn.

The effect of gestational age and cervical length measurements in the prediction of spontaneous preterm birth in twin pregnancies: an individual patient level meta-analysis

OBJECTIVE

To assess the effect of gestational age (GA) and cervical length (CL) measurements at transvaginal ultrasound (TVUS) in the prediction of preterm birth in twin pregnancy.

DESIGN

Individual patient data (IPD) meta-analysis.

SETTING

International multicentre study.

POPULATION

Asymptomatic twin pregnancy.

METHODS

MEDLINE and EMBASE searches were performed and IPD obtained from authors of relevant studies. Multinomial logistic regression analysis determined probabilities for birth at ≤28(+0) , 28(+1) to 32(+0) , 32(+1) to 36(+0) , and ≥36(+1) weeks as a function of GA at screening and CL measurements.

MAIN OUTCOME MEASURES

Predicted probabilities for preterm birth at ≤28(+0) , 28(+1) to 32(+0) , and 32(+1) to 36(+0) .

RESULTS

A total of 6188 CL measurements were performed on 4409 twin pregnancies in 12 studies. Both GA at screening and CL had a significant and non-linear effect on GA at birth. The best prediction of birth at ≤28(+0) weeks was provided by screening at ≤18(+0) weeks (P < 0.001), whereas the best prediction of birth between 28(+1) and 36(+0) weeks was provided by screening at ≥24(+0) weeks (P < 0.001). Negative prediction value of 100% for birth at ≤28(+0) weeks is achieved at CL 65 mm and 43 mm at ultrasound GA at ≤18(+0) weeks and at 22(+1) to 24(+0) weeks, respectively.

CONCLUSION

In twin pregnancies, prediction of preterm birth depends on both CL and the GA at screening. When CL is <30 mm, screening at ≤18(+0) weeks is most predictive for birth at ≤28(+0) weeks. Later screening at >22(+0) weeks is most predictive of delivery at 28(+1) to 36(+0) weeks. In twins, we recommend CL screening in twins to commence from ≤18(+0) weeks.

TWEETABLE ABSTRACT

An individual patient meta-analysis assessing gestation and CL in the prediction of preterm birth in twins.

Non-invasive electrohysterogram recording using flexible concentric ring electrode

Non-invasive electrohysterogram (EHG) recording could provide valuable information about uterine dynamics. Bipolar EHG has usually been performed using monopolar disposable electrodes. Recently concentric ring electrodes have been used for EHG recordings so as to acquire more localized electrical activity which may be helpful for deducing uterine contraction efficiency. Nevertheless concentric ring electrodes have commonly been implemented in rigid substrates. Therefore they do not adapt to the body surface curvature which may cause discomfort for patients and a poor contact between electrode and skin. The aim of this paper is to examine the feasibility of picking up EHG signals (BC-EHG) using a new flexible tripolar concentric ring (TCR) electrode placed on the abdominal surface, and to compare it with the conventional bipolar recordings. For this purpose, a total of 7 recording sessions were carried out in 7 pregnant women. Each recording implied simultaneous acquisition of one bipolar EHG signal and of two bipolar concentric EHG (BC-EHG) signals using the flexible TCR electrode. Then a set of temporal and spectral parameters was computed from both bipolar EHG and BC-EHG bursts. Experimental results show no noticeable difference in duration and in dominant frequency in Fast Wave High frequency range. Nonetheless, the low frequency content (0.1-0.2 Hz) of BC-EHG records is smaller than that of bipolar record. These results suggest that the new flexible TCR electrode permits to pick up uterine electrical activity and may provide additional information for deducing uterine efficiency.

Feasibility and analysis of bipolar concentric recording of electrohysterogram with flexible active electrode

The conduction velocity and propagation patterns of the electrohysterogram (EHG) provide fundamental information on the electrophysiological condition of the uterus. However, the accuracy of these measurements can be impaired by both the poor spatial selectivity and sensitivity to the relative direction of the contraction propagation associated with conventional disc electrodes. Concentric ring electrodes could overcome these limitations. The aim of this study was to examine the feasibility of picking up surface EHG signals using a new flexible tripolar concentric ring electrode (TCRE), and to compare these signals with conventional bipolar recordings. Simultaneous recording of conventional bipolar signals and bipolar concentric EHG (BC-EHG) were carried out on 22 pregnant women. Signal bursts were characterized and compared. No significant differences were found between the channels in either duration or dominant frequency in the Fast Wave High frequency range. Nonetheless, the high pass filtering effect of the BC-EHG recordings gave lower frequency content between 0.1 and 0.2 Hz. Although the BC-EHG signal amplitude was about 5-7 times smaller than that of bipolar recordings, a similar signal-to-noise ratio was obtained. These results suggest that the flexible TCRE is able to pick up uterine electrical activity and could provide additional information for deducing the uterine electrophysiological condition.

Effectiveness of progestogens to improve perinatal outcome in twin pregnancies: an individual participant data meta-analysis

BACKGROUND

In twin pregnancies, the rates of adverse perinatal outcome and subsequent long-term morbidity are substantial, and mainly result from preterm birth (PTB).

OBJECTIVES

To assess the effectiveness of progestogen treatment in the prevention of neonatal morbidity or PTB in twin pregnancies using individual participant data meta-analysis (IPDMA).

SEARCH STRATEGY

We searched international scientific databases, trial registration websites, and references of identified articles.

SELECTION CRITERIA

Randomised clinical trials (RCTs) of 17-hydroxyprogesterone caproate (17Pc) or vaginally administered natural progesterone, compared with placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Investigators of identified RCTs were asked to share their IPD. The primary outcome was a composite of perinatal mortality and severe neonatal morbidity. Prespecified subgroup analyses were performed for chorionicity, cervical length, and prior spontaneous PTB.

MAIN RESULTS

Thirteen trials included 3768 women and their 7536 babies. Neither 17Pc nor vaginal progesterone reduced the incidence of adverse perinatal outcome (17Pc relative risk, RR 1.1; 95% confidence interval, 95% CI 0.97-1.4, vaginal progesterone RR 0.97; 95% CI 0.77-1.2). In a subgroup of women with a cervical length of ≤25 mm, vaginal progesterone reduced adverse perinatal outcome when cervical length was measured at randomisation (15/56 versus 22/60; RR 0.57; 95% CI 0.47-0.70) or before 24 weeks of gestation (14/52 versus 21/56; RR 0.56; 95% CI 0.42-0.75).

AUTHOR'S CONCLUSIONS

In unselected women with an uncomplicated twin gestation, treatment with progestogens (intramuscular 17Pc or vaginal natural progesterone) does not improve perinatal outcome. Vaginal progesterone may be effective in the reduction of adverse perinatal outcome in women with a cervical length of ≤25 mm; however, further research is warranted to confirm this finding.

Chemical ecology of canarian laurel forest: Toxic diterpenes fromPersea indica (Lauraceae)

The tree speciesP. indica (Lauraceae) is an important endemism in the Canary Islands laurel forest and can readily be distinguished by its defoliated appearance due to the seasonal action of wild rats (Rattus rattus), which eat the plant and become intoxicated. These observations and the phytochemical interest of this plant species led us to study the potentially toxic chemicals responsible for such action. We found that an ethanolic extract ofP. indica and its water fraction were toxic when injected into laboratory mice. The mice also died after ingestion of the stems and showed a significant preference for those extracted and rehydrated with an 8% aqueous extract solution when compared with the water control. Two compounds that have been isolated from the toxic fraction and identified by spectroscopic methods are the polyhydroxy pentacyclic diterpenes ryanodol and cinnceylanol. Possible ecological implications are discussed.

Prediction of labor using non-invasive Laplacian EHG recordings

Non-invasive electrohysterogram (EHG) recordings could be used as an alternative technique for monitoring uterine dynamics. Bipolar recordings of EHG have proven to provide valuable information to predict labor. Recently it has been stated that uterine EHG bursts could also be identified in Laplacian recordings on abdominal surface. Taking into account that Laplacian potential technique permits to acquire more localized electrical activity than conventional recordings; these recordings could also be helpful for deducing uterine contraction efficiency. The aim of this paper is to examine the feasibility of Laplacian potential EHG recording for labor prediction and to compare it with monopolar recordings. To this purpose, a total of 42 EHG recordings were acquired from women of similar gestational age: 29 antepartum patients, and 13 patients in labor. Then linear and non-linear classifiers have been implemented using EHG burst parameters as input features. Experimental results show significant differences in temporal and spectral parameters in both monopolar and Laplacian potential recordings between the two groups. In addition, support vector machine based classifier achieved an accuracy of 93% for labor prediction for monopolar recordings, 92% for bipolar recordings and 91% for Laplacian potential.

[Influence of pregnancy on refractive parameters after LASIK surgery]

OBJECTIVES

Different ocular changes and complications of refractive surgery such as photorefractive keratectomy (PRK) due to pregnancy have been described in the last few years. However there is no information about the possible problems of laser in situ keratomileusis (LASIK) in pregnant women. Our objective was to study how physiological changes secondary to pregnancy could alter the refractive situation in pregnant women who have undergone LASIK surgery. We show the results obtained due to the changes between the first two trimesters of the pregnancy.

METHODS

A prospective and observational study was conducted in which one study group, made up of 9 patients who had undergone LASIK surgery before becoming pregnant, was compared with a control group of 9 patients with non-surgically corrected refractive problems. The following measurements were made in both groups in the first and second trimesters of the pregnancy; visual acuity, the best corrected visual acuity, tonometry, ocular anatomical characteristics by biometry, and refractive and corneal study by Pentacam(®).

RESULTS

Signicant changes were observed in the cylinder and spherical equivalent between the two trimesters in both groups. Visual acuity and spherical equivalent show a strong trend towards worsening, which was more significant in the study group. The patients of this group who had a larger pre-surgical defect showed lower modifications during the six first months of pregnancy.

CONCLUSIONS

The majority of women who require laser refractive surgery are are between 20-30 years old, thus in many cases corneal surgery is followed by at least one pregnancy, with different possible ophthalmological effects. The conclusions that may be derived from this study are that the assessment of the refractive changes in surgically operated corneas may be biomechanically weakened on being subjected to physiological hormone stimulation as happens during gestation.

Recording of electrohysterogram laplacian potential

Preterm birth is the main cause of the neonatal morbidity. Noninvasive recording of uterine myoelectrical activity (electrohysterogram, EHG) could be an alternative to the monitoring of uterine dynamics which are currently based on tocodynamometers (TOCO). The analysis of uterine electromyogram characteristics could help the early diagnosis of preterm birth. Laplacian recordings of other bioelectrical signals have proved to enhance spatial selectivity and to reduce interferences in comparison to monopolar and bipolar surface recordings. The main objective of this paper is to check the feasibility of the noninvasive recording of uterine myoelectrical activity by means of laplacian techniques. Four bipolar EHG signals, discrete laplacian obtained from five monopolar electrodes and the signals picked up by two active concentric-ringed-electrodes were recorded on 5 women with spontaneous or induced labor. Intrauterine pressure (IUP) and TOCO were also simultaneously recorded. To evaluate the uterine contraction detectability of the different noninvasive methods in comparison to IUP the contractions consistency index (CCI) was calculated. Results show that TOCO is less consistent (83%) than most EHG bipolar recording channels (91%, 83%, 87%, and 76%) to detect the uterine contractions identified in IUP. Moreover laplacian EHG signals picked up by ringed-electrodes proved to be as consistent (91%) as the best bipolar recordings in addition to significantly reduce ECG interference.

DIAGNOSIS, MANAGEMENT AND PROGNOSIS OF VAGINAL EROSION AFTER TRANSOBTURATOR SUBURETHRAL TAPE PROCEDURE USING A NONWOVEN THERMALLY BONDED POLYPROPYLENE MESH

PURPOSE

We studied the diagnosis, management and prognosis of vaginal mesh erosion using a thermally bonded nonwoven polypropylene mesh in a transobturator suburethral tape procedure for the surgical treatment of stress urinary incontinence in women.

MATERIALS AND METHODS

A total of 65 patients diagnosed with stress urinary incontinence underwent a transobturator suburethral tape procedure with a fusion welded, nonwoven, nonknitted polypropylene mesh, with or without a central silicone coated section, at our institution. All women were followed and if vaginal erosion was diagnosed, cystoscopy and vaginoscopy were performed, the mesh was partially or completely removed and, if necessary, posterior cough test and urodynamic study were performed.

RESULTS

Of the 65 patients 9 (13.8%) were diagnosed with vaginal erosion at the vaginal incision during a relatively long postoperative period (mean 290 days). All presented with vaginal discharge and 1 had a severe complication (obturator abscess). Complete mesh removal was necessary in 8 patients and only 2 (22%) had recurrent stress urinary incontinence.

CONCLUSIONS

A 13.8% rate of vaginal mesh erosion using a nonwoven thermally bonded polypropylene mesh was reported. This complication was probably due to the characteristics of the mesh and not to the transobturator approach. Complete removal of the tape is recommended and the continence status prognosis is good (78%).

Epstein-Barr virus positivity in primary vaginal lymphoma

BACKGROUND

Primary non-Hodgkin lymphoma (NHL) of the vagina is a rare location. Its association with the Epstein-Barr virus (EBV) has been only reported in another case. We present a new case, emphasizing the oncogenetic relevance of EBV.

CASE REPORT

A 45-year-old woman with a pelvic pain revealed in her vaginal inspection a thick and hard vaginal plug with a "paving stone" appearance. The biopsy reported a vaginal non-Hodgkin lymphoma type B of intermediate cell, with positive result for EBV. After treatment, a complete remission was obtained.

CONCLUSION

The EBV is the main responsible for the non-Hodgkin lymphoma; classified as a group I carcinogen, it has been associated with a variety of neoplastic tumors, although it is unusual with extranodal type B diffuse lymphoma.

Antibody response and antigen-specific gamma-interferon profiles of vaccinated and unvaccinated pregnant sheep experimentally infected with Brucella melitensis

It is well known that the immune response in sheep against Brucella melitensis is subject to individual variation, depending on diverse factors. It bears asking whether these factors (e.g. clinical disease, active infection, state of previous immunity), when affecting a group, can cause variation in the performance of different diagnostic tests. To clarify some of the circumstances in which this immune response can vary, we examine the immune-response profile of sheep protected against the clinical disease by prior vaccination with strain Rev. 1 in comparison with the profile of unprotected females showing the classical brucellosis symptoms. An experimental infection was provoked at midpregnancy under controlled conditions of both non-vaccinated (n=7) and previously Rev.1-vaccinated ewes (n=5). Their immune response was monitored from 7 to 9 weeks before abortion or normal birth to 30 weeks afterwards. Antibody response was assessed by classical tests (Rose Bengal test, complement fixation test (CFT)) in comparison with other diagnostic tests (indirect ELISA (iELISA), competitive ELISA (cELISA), fluorescence polarization assay (FPA), immunocapture test (ICT)). In addition, the cell-mediated immune response was indirectly evaluated by the in vitro antigen-specific release of gamma-interferon. The antibody levels and antigen-specific gamma-IFN profile of the non-vaccinated ewes having the disease and excreting the pathogen was notably high and differed significantly (P<0.05 or P<0.01) from those of vaccinated ewes that neither contracted brucellosis nor excreted the pathogen. In general, all the tests detect the infection in the non-vaccinated ewes with substantial effectiveness. It can be concluded that the high levels of circulating antibodies and of antigen-specific gamma-IFN are related to active Brucella infection. Similarly, the state of protection against the disease, but not necessarily against infection, due to a previous immunization with the Rev. 1 vaccination, appears to be responsible for a low level of detectable immune response. Nevertheless, the design of the study limits conclusions to pregnant ewes and cannot be extrapolated to non-pregnant ewes or rams. Likewise, the study provides no information on animals which are carriers of B. melitensis.

Duration of ruptured membranes and extended labor are risk factors for HIV transmission

OBJECTIVES

To determine the effects of duration of ruptured membranes (DRM) and duration of labor in HIV transmission.

METHODS

A retrospective cohort study of 366 HIV-infected pregnant women and their infants analyzed the effects of these two variables; the cut-off point for transmission increase was estimated using a ROC curve. A multivariate analysis was performed with the most important risk factors according to the literature: maternal age, lymphocyte count, use of invasive procedures during gestation, antiretroviral treatment during pregnancy and labor, mode of delivery, newborn weight, DRM, labor duration, and the interaction of these last two factors.

RESULTS

The cut-off points were estimated at 6 h for DRM and at 5 h for labor duration. A lymphocyte count below 500 cells/ml, use of invasive procedures, use of antiretroviral treatment during pregnancy and interaction between DRM, and labor duration remained significant in perinatal HIV transmission (P<0.05).

CONCLUSIONS

An increased DRM increased perinatal HIV transmission when it was associated with prolonged labor.

Comparison between two strategies for umbilical cord blood collection

The use of cord blood (CB) for transplantation has increased greatly in recent years. The collection strategy is the first step in collecting good-quality CB units. There are two main techniques for collecting CB from the umbilical vein: in the delivery room while the placenta is still in the uterus by midwives and obstetricians or in an adjacent room after placental delivery by CB bank trained personnel. In this study, the benefits and disadvantages between the two different CB collection strategies were evaluated, in order to improve CB bank methodology. Valencia CB bank maintains the two different collection strategies. CB was obtained from 569 vaginal and 70 caesarean deliveries and obstetrical and clinical charts were reviewed. Before processing CB units, volume was calculated and samples were drawn for cell counts. After processing and before cryopreservation samples were drawn for cell counts, CD34+cell analysis, viability, clonogenic assays and microbiology were drawn directly from the bags. We compared the efficiency of the two collection techniques. Obstetric data and umbilical CB were obtained from 569 vaginal (264 collected in utero and 305 collected ex utero) and 70 caesarean deliveries. The proportion of excluded CB units before processing was 33% for vaginal ex utero, 25% for vaginal in utero and 46% for caesarean deliveries. Differences were statistically significant. For vaginal deliveries a larger volume and a higher number of nucleated cells, percentage of CD34+ cells and colony-forming units (CFUs) were harvested in the in utero collection group. There was no statistical difference between CB collected after placental expulsion from vaginal and caesarean deliveries. Comparison between all vaginal and caesarean deliveries did not show any difference. We conclude that the mode of collection influences the haematopoietic content of CB donations. Collection before placental delivery is the best approach to CB collection and allows optimisation of CB bank methodology. Caesarean deliveries seem to contain similar progenitor content to vaginal deliveries.

Bifurcations and global stability of synchronized stationary states in the Kuramoto model for oscillator populations

Bistability between synchronized stationary states is shown to occur in large populations of nonlinearly coupled random oscillators (Kuramoto model), governed by trimodal natural frequency distributions. Numerical simulations and a numerical investigation of bifurcating states provide evidence of global stability of such states, subject to unimodal, bimodal, and trimodal frequency distributions. All this may be important in the framework of large superconducting Josephson junctions arrays, as well as of neural networks.

Effects of prandial glycemic changes on objective fetal heart rate parameters

BACKGROUND

There is confusion in the literature about the potential effect of maternal glucose levels on the fetal heart rate (FHR) cardiotocographic interpretation.

METHODS

STUDY DESIGN

prospective clinical descriptive study.

SUBJECTS

21 pregnant women with diabetes mellitus, 23 women with gestational diabetes and 18 healthy non-diabetic pregnant volunteers (control group).

TREATMENT

maternal capillary glucose measurement and objective FHR analysis (Oxford System 8002) pre- and 1 h post-meal.

STATISTICAL ANALYSIS

descriptive statistics. Student t-tests and Pearson correlation studies.

RESULTS

Maternal capillary glucose levels ranged between 2.7-10.5 mmol/l pre-meal and 4.2 14.8 mmol/l post-meal. The differences between objective FHR parameters pre- and postmeal were not significant in any of the groups of women studied. No correlation was found between prandial glycemic and FHR changes. Women with optimal and suboptimal glycemic control exhibited similar objective FHR parameters pre- and post-meal. Women with gestational diabetes showed similar prandial cardiotocographic changes irrespective of whether they were on insulin therapy or on hypoglycemic diet only.

CONCLUSIONS

Objective FHR parameters are unaffected by prandial glycemic changes over a wide range of maternal glucose levels. Timing the non-stress test in relation to the meals seems irrelevant in clinical practice.

Intrapartum fetal invasive procedures and perinatal transmission of HIV

OBJECTIVE

To study the effect of intrapartum use of fetal invasive procedures (scalp electrodes or scalp pH sampling) on perinatal transmission rate of HIV.

STUDY DESIGN

We compared the perinatal transmission of 57 HIV pregnancies in which invasive procedures (IP) were performed with a control group of 214 pregnancies without IP. We controlled for potentially risk factors (maternal CD4 level, gestational age, antiretroviral therapy use, duration of rupture of membranes (ROM), length of labor and mode of delivery) by stratification and logistic regression.

RESULTS

Transmission rate in the group with IP was 26.3% (15/57) versus 13.6% (29/214) in the control group, relative risk (RR) 1.9, 95% CI (1.1-3.4). By logistic regression we observed three significant factors involved in transmission of HIV: low maternal CD4 level (odds ratio (OR)=3.3, 95% CI=1.2-9.4), duration of ROM (OR=2.9, 95% CI=1.1-7.9) and IP use (OR=3.5, CI 95%=1.2-9.6). Interaction between duration of ROM and IP are also significant (OR=5.1, CI 95%=1.5-17.5).

CONCLUSIONS

Intrapartum use of fetal scalp electrodes or fetal scalp pH sampling increases the perinatal transmission of HIV and should therefore be avoided in HIV patients.

Prospective double-arm study of fibrinolysis in surgical patients

BACKGROUND

During surgery, the balance between thrombosis and fibrinolysis is altered. Methods reported to increase fibrinolysis, such as compression devices, may reduce venous thrombosis. However, there are no prospective studies comparing methods and the effect on fibrinolysis.

MATERIALS AND METHODS

In a prospective study, general surgical patients were randomized to either sequential compression devices (Group 1) or subcutaneous heparin (Group 2), and fibrinolysis factors were measured in order to determine the effect on the fibrinolysis system. Blood samples were drawn at a similar time of the day with the tourniquet off. Specifically, t-PA antigen, plasminogen activator inhibitor-1 (PAI-1), and D-dimer were measured preoperatively (preop) and on Postoperative Days (POD) 1 and 7 by the ELISA method. Fibrinolysis factors were reported as the mean +/- SD and as percentage change from preoperative values. Noninvasive vascular studies were performed preop, and on POD 1, 7, and 30, by an examination of the infrainguinal venous system and external iliac veins in bilateral lower extremities. Nonambulatory patients were excluded from the study and DVT prophylaxis methods were initiated at surgery and used through POD 2.

RESULTS

For the 136 patients in the study, there were no differences in clinical characteristics such as age, surgical time (all > 60 min), anesthesia type (general or spinal), type of surgical procedure, or other risk factors for DVT. Two DVTs occurred at POD 1 and 30 (both Group 2), and one pulmonary embolism in each group (POD 7 for Group 1; POD 1 for Group 2). For subjects without thrombosis, D-dimer changes were parallel for both groups, increasing through POD 7. Similarly, t-PA antigen levels rose from baseline on POD 1 in both groups, with a return toward baseline by POD 7. The PAI-1 levels increased on POD 1 in both groups, but severalfold more in Group 1 (compression devices). The elevation in PAI-1 decreased by 50% in Group 1 by POD 7, while values returned to normal in Group 2. These changes were not significant using the Mann-Whitney test. Only three patients had thrombotic episodes so that data on changes in fibrinolysis factors are difficult to compare with the larger group.

CONCLUSIONS

This is the first report of a prospective, randomized comparison of fibrinolysis factors using sequential compression devices in comparison to low dose unfractionated heparin in general surgical patients, and comparing postoperative values to preop. Both groups showed an enhanced fibrinolysis by elevation in t-PA antigen and D-dimer on POD 1, as expected when fibrinolysis occurs. While PAI-1 and t-PA work in parallel, the marked elevation of PAI-1 on POD 1 (although only slightly above reference values) and continuing into POD 7 for subjects using compression devices requires further inquiry. The elevation of PAI-1 in the face of elevated t-PA and D-dimer has been reported, but the comparison between patients using sequential compression devices and mini-dose heparin has not been reported. The reason for the elevation requires additional study into other influences on the synthesis, secretion, and/or function of PAI-1 that do not affect t-PA.