Diagnostic Performance of a telephone questionnaire for fracture-related infections (FRIs) in open tibia fracture patients in Tanzania

INTRODUCTION

Fracture-related infections (FRIs) are a major cause of trauma-associated morbidity worldwide. In 2018, an expert group supported by the AO Foundation, European Bone and Joint Infection Society developed a consensus definition of FRI. Still, there is limited knowledge on the applicability of this definition in low- and middle-income countries (LMICs). Given the unique barriers that cause low follow-up rates for orthopaedic trauma patients in LMICs, this study aims to evaluate the diagnostic performance of a telephone questionnaire in identifying patients with FRIs after open tibia fracture fixation in Tanzania.

MATERIALS AND METHODS

Patients from a randomized controlled trial investigating the infection prevention benefit of locally applied gentamycin for open tibial fractures were included. Patients completed FRI based telephone questionnaires 7-10 days prior to scheduled follow-ups at 6 weeks, 3 months, 6 months, 9 months, and 1 year. The questionnaire included two "confirmatory" criteria questions for FRI (i.e., open wound and purulent drainage) and three "suggestive" criteria questions (i.e., wound drainage, fever, and warmth). Contingency tests were performed to identify the sensitivity and specificity between answers and adjudicated FRI diagnoses at the corresponding in-person follow-up. Data was analysed using STATA version 15.0 and MedCalc's online diagnostic test calculator.

RESULTS

There were a total of 234 complete questionnaires and 85 unique patients included. The sensitivity and specificity of having any positive answer in the questionnaire was highest at 6 months (100 % and 92.5 %, respectively). For all time-points pooled, sensitivity was 71.4 % and specificity was 93.0 %. Drainage had the highest sensitivity (71.4 %) while fever had the highest specificity (99.6 %). For confirmatory criteria, sensitivity was 14.3 % and specificity was 96.0 %. Contrastingly, the sensitivity for suggestive criteria was higher (71.4 %), with a similar specificity (93.8 %).

CONCLUSION

Our study indicates that telephone questionnaires have adequate diagnostic performance when assessing FRIs. The presence of drainage identified the majority of patients with FRI, and specificities were high across confirmatory and suggestive criteria. Our study is one of the first to evaluate telephone questionnaires as a diagnostic tool for FRIs in patients with open tibia fractures in a LMIC hospital and validates the FRI consensus definition criteria.

Delays in Debridement of Open Femoral and Tibial Fractures Increase Risk of Infection

BACKGROUND

Infection remains a costly, devastating complication following the treatment of open fractures. The appropriate timing of debridement is controversial, and available evidence has been conflicting.

METHODS

This study is a retrospective analysis of the SIGN (Surgical Implant Generation Network) Surgical Database (SSDB), a prospective registry of fracture cases in predominantly low-resource settings. Skeletally mature patients (≥16 years of age) who returned for follow-up at any time point after intramedullary nailing of an open femoral or tibial fracture were included. Patients were excluded if they had delays in debridement exceeding 7 days after the injury. Utilizing a model adjusting for potential confounders, including patient demographic characteristics, injury characteristics, country income level, and hospital type and resources, local logistic regression analysis was performed to evaluate the probability of infection with increasing time to debridement in 6-hour increments.

RESULTS

In this study, 27.3% of patients met the eligibility criteria and returned for follow-up, with a total of 10,651 fractures from 61 countries included. Overall, the probability of infection increased by 0.17% for every 6-hour delay in debridement. On subgroup analysis, the probability of infection increased by 0.23% every 6 hours for Gustilo-Anderson type-III injuries compared with 0.13% for Gustilo-Anderson type-I or II injuries. The infection risk increased every 6 hours by 0.18% for tibial fractures compared with 0.13% for femoral fractures.

CONCLUSIONS

There was a linear and cumulative increased risk of infection with delays in debridement for open femoral and tibial fractures. Such injuries should be debrided promptly and expeditiously. The size and international nature of this cohort make these findings uniquely generalizable to nearly all environments where such injuries are treated.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

A pilot, masked, randomized controlled trial to evaluate local gentamicin versus saline in open tibial fractures (pGO-Tibia)

Background

Open tibial fractures have a high risk of infection that can lead to severe morbidity. Antibiotics administered locally at the site of the open wound are a potentially effective preventive measure, but there are limited data evaluating aminoglycoside antibiotics. The objective of this study was to assess the feasibility of a clinical trial to test the efficacy of local gentamicin in reducing the risk of fracture-related infection after open tibial fracture.

Methods

This study is a single-center, pilot, masked, randomized controlled trial conducted at the Muhimbili Orthopaedic Institute. Participants were randomized intraoperatively after wound closure to receive gentamicin solution or normal saline solution injected at the fracture site. Follow-ups were completed at 2 weeks, 6 weeks, 3 months, 6 months, 9 months, and 1 year postoperatively. The primary feasibility outcomes were the rate of enrollment and retention. The primary clinical outcome was the occurrence of fracture-related infection.

Results

Of 199 patients screened, 100 eligible patients were successfully enrolled and randomized over 9 months (11.1 patients/month). Complete data were recorded at baseline and follow-up for >95% of cases. The rate of follow-up at 6 weeks, 3 months, 6 months, 9 months, and 1 year were 70%, 68%, 69%, 61%, and 80%, respectively. There was no difference in adverse events or any of the measured primary and secondary outcomes.

Conclusion

This pilot study is among the first to evaluate locally administered gentamicin in open tibial fractures. Results indicate a rigorous clinical trial with acceptable rates of enrollment and follow-up to address this topic is possible in this setting.

The Scratch-Collapse Test: A Systematic Review and Statistical Analysis

BACKGROUND

The scratch-collapse test (SCT) is a provocative maneuver used to diagnose compressive neuropathies. Despite multiple studies supporting its use, the SCT remains a controversial point in the literature in regard to its exact clinical application. We performed a systematic review and statistical analysis to provide statistical data on SCT outcomes and elucidate its role in diagnosing compressive conditions.

METHODS

We performed a systematic review of the literature according to Preferred Reporting for Systematic Reviews and Meta-Analyses guidelines. We extracted data of patients with outcomes on the SCT (yes/no) and on an accepted gold standard examination (electrodiagnostic studies). These data were analyzed using a statistical software program to generate the sensitivity and specificity values of the pooled data, as well as kappa agreement statistics.

RESULTS

For patients with carpal tunnel, cubital tunnel, peroneal, and pronator compressive neuropathies, the overall sensitivity of the SCT was 38%, and the specificity was 94%, with the kappa statistic approximately 0.4. Sensitivity and specificity values were higher for cubital tunnel syndrome and peroneal compression syndrome but lower for carpal tunnel syndrome. Pronator syndrome was also examined, but the data were inadequate for analysis.

CONCLUSIONS

The SCT is a useful adjunct in the armament of diagnostic tools for the hand surgeon. Given its low sensitivity and high specificity, SCT should be used as a confirmatory test, rather than as a diagnostic screening test. More analyses are needed to identify subtler applications.

Orthopaedic trauma observerships in North America for international surgeons: the visitors' perspective

International observerships are one of many efforts aimed at addressing disparities in orthopaedic trauma care globally. However, their impact on visiting surgeons and their home countries, as well as the challenges faced by participating surgeons, are not well-documented.

Methods

A survey was distributed to overseas surgeons who participated in an orthopaedic trauma observership from 2009 to 2020. Surgeons were identified through North American institutions previously recognized by the authors as having hosted international observerships. Information gathered included participant demographics, details of and perceived impact of the observership, and barriers faced before, during, and after the program. Responses from 148 international surgeons (ISs) from 49 countries were analyzed.

Results

Sixty percent of observerships were at academic programs, 57% lasted 1-3 months, and 60% were self-funded. Participants identified cost and housing as primary barriers. After completing their observership, lack of funding, equipment and support staff, and excessive workload prevented participants from implementing changes at their clinical practice. Most observers believed that they gained relevant clinical (89%) and surgical knowledge (67%) and developed a professional network of North American hosts (63%). The most common suggested changes to the observership were greater hands-on experience in the operating room and structured goal setting relevant to the visiting surgeon.

Conclusions

Visiting surgeons find North American orthopaedic trauma observerships helpful in improving their surgical and clinical skills. However, financial constraints and resource limitations at their clinical practice and limited operative experience during the observership present barriers to maximizing this clinical experience. To enhance the relevance of clinical observerships for ISs and impact global orthopaedic trauma care, the unique needs and challenges facing ISs must be addressed.

Level of Evidence

IV-Cross-Sectional Study.

Outcomes of Intramedullary Nailing and External Fixation of Open Tibial Fractures: Three to Five-Year Follow-up of a Randomized Clinical Trial

BACKGROUND

While surgeons in low and middle-income countries have increasing experience with intramedullary nailing (IMN), external fixation (EF) continues to be commonly used for the management of open tibial fractures. We examined outcomes with extended follow-up of the participants enrolled in a clinical trial comparing these treatments.

METHODS

Adults who were ≥18 years old with acute AO/OTA type-42 open tibial shaft fractures were randomly assigned to statically locked, hand-reamed IMN or uniplanar EF. These participants were reevaluated 3 to 5 years after treatment. The primary outcome was death or reoperation for the treatment of deep infection, nonunion, or malalignment. Unresolved complications such as persistent fracture-related infection, nonunion, or malalignment were collected and analyzed. Secondary outcomes included the EuroQol-5 Dimension-3 Level (EQ-5D-3L) questionnaire, the Function IndeX for Trauma (FIX-IT) score, radiographic alignment, and the modified Radiographic Union Scale for Tibial fractures (mRUST).

RESULTS

Of the originally enrolled 240 participants,126 (67 managed with IMN and 59 managed with EF) died or returned for follow-up at a mean of 4.0 years (range, 2.9 to 5.2 years). Thirty-two composite primary events occurred, with rates of 23.9% and 27.1% in the IMN and EF groups, respectively. Six of these events (3 in the IMN group and 3 in the EF group) were newly detected after the original 1-year follow-up. Unresolved complications in the form of chronic fracture-related infection or nonunion were present at long-term follow-up in 25% of the participants who sustained a primary event. The EQ-5D-3L index scores were similar between the 2 groups and only returned to preinjury levels after 1 year among patients without complications or those whose complications resolved.

CONCLUSIONS

This observational study extended follow-up for a clinical trial assessing IMN versus EF for the treatment of open tibial fractures in sub-Saharan Africa. At a mean of 4 years after injury, fracture-related infection and nonunion became chronic conditions in nearly a quarter of the participants who experienced these complications, regardless of reintervention.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Noncompliance to iodine supplementation recommendation is a risk factor for iodine insufficiency in Portuguese pregnant women: results from the IoMum cohort

PURPOSE

After a recommendation for iodine supplementation in pregnancy has been issued in 2013 in Portugal, there were no studies covering iodine status in pregnancy in the country. The aim of this study was to assess iodine status in pregnant women in Porto region and its association with iodine supplementation.

METHODS

A cross-sectional study was conducted at Centro Hospitalar Universitário São João, Porto, from April 2018 to April 2019. Pregnant women attending the 1st trimester ultrasound scan were invited to participate. Exclusion criteria were levothyroxine use, gestational age < 10 and ≥ 14 weeks, non-evolutive pregnancy at recruitment and non-signing of informed consent. Urinary iodine concentration (UIC) was measured in random spot urine by inductively coupled plasma-mass spectrometry.

RESULTS

Median UIC was 104 μg/L (IQR 62-189) in the overall population (n = 481) of which 19% had UIC < 50 µg/L. Forty three percent (n = 206) were not taking an iodine-containing supplement (ICS) and median UIC values were 146 µg/L (IQR 81-260) and 74 µg/L (IQR 42-113) in ICS users and non-users, respectively (p < 0.001). Not using an ICS was an independent risk factor for iodine insufficiency [adjusted OR (95% CI) = 6.00 (2.74, 13.16); p < 0.001]. Iodised salt use was associated with increased median iodine-to-creatinine ratio (p < 0.014).

CONCLUSIONS

A low compliance to iodine supplementation recommendation in pregnancy accounted for a mild-to-moderately iodine deficiency. Our results evidence the need to support iodine supplementation among pregnant women in countries with low household coverage of iodised salt. Trial registration number NCT04010708, registered on the 8th July 2019.

Risk Factors for Delayed Hospital Admission and Surgical Treatment of Open Tibial Fractures in Tanzania

BACKGROUND

Open fractures, especially of the tibia, require prompt intervention to achieve optimal patient outcomes. While open tibial shaft fractures are common injuries in low- and middle-income countries (LMICs), there is a dearth of literature examining delays to surgery for these injuries in low-resource settings. This study investigated risk factors for delayed management of open tibial fractures in Tanzania.

METHODS

We conducted an ad hoc analysis of adult patients enrolled in a prospective observational study at a tertiary referral center in Tanzania from 2015 to 2017. Multivariable models were utilized to analyze risk factors for delayed hospital presentation of ≥2 hours, median time from injury to the treatment hospital, and delayed surgical treatment of ≥12 hours after admission among patients with diaphyseal open tibial fractures.

RESULTS

Two hundred and forty-nine patients met the inclusion criteria. Only 12% of patients used an ambulance, 41% were delayed ≥2 hours in presentation to the first hospital, 75% received an interfacility referral, and 10% experienced a delay to surgery of ≥12 hours after admission. After adjusting for injury severity, having insurance (adjusted odds ratio [aOR] = 0.48; 95% confidence interval [CI] = 0.24 to 0.96) and wounds with approximated skin edges (aOR = 0.37; 95% CI = 0.20 to 0.66) were associated with a decreased risk of delayed hospital presentation. Interfacility referrals (2.3 hours greater than no referral; p = 0.015) and rural injury location (10.9 hours greater than urban location; p < 0.001) were associated with greater median times to treatment hospital admission. Older age (aOR = 0.54 per 10 years; 95% CI = 0.31 to 0.95), single-person households (aOR = 0.12 compared with ≥8 people; 95% CI = 0.02 to 0.96), and an education level greater than pre-primary (aOR = 0.16; 95% CI = 0.04 to 0.62) were associated with fewer delays to surgery of ≥12 hours after admission.

CONCLUSIONS

Prehospital network and socioeconomic characteristics are associated with delays to open tibial fracture care in Tanzania. Reducing interfacility referrals and implementing surgical cost-reduction strategies may help to reduce delays to open fracture care in LMICs.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association of comorbid depression with inpatient outcomes in critical limb ischemia

There is a growing body of evidence that peripheral artery disease (PAD) may be impacted by depression. The objective of this study is to determine whether outcomes, primarily major amputation, differ between patients with depression and those without who presented to hospitals with critical limb ischemia (CLI), the end-stage of PAD. A retrospective cohort of patients hospitalized for CLI during 2012 and 2013 was identified from the National Inpatient Sample (NIS) using ICD-9 codes. The primary outcome was major amputation and secondary outcomes were length of stay and other complications. The sample included 116,008 patients hospitalized for CLI, of whom 10,512 (9.1%) had comorbid depression. Patients with depression were younger (64 ± 14 vs 67 ± 14 years, p < 0.001) and more likely to be female (55% vs 41%, p < 0.001), white (73% vs 66%, p < 0.001), and tobacco users (46% vs 41%, p < 0.001). They were also more likely to have prior amputations (9.8% vs 7.9%, p < 0.001). During the hospitalization, the rate of major amputation was higher in patients with comorbid depression (11.5% vs 9.1%, p < 0.001). In multivariable analysis, excluding patients who died prior to/without receiving an amputation ( n = 2621), comorbid depression was associated with a 39% increased odds of major amputation (adjusted OR 1.39, 95% CI 1.30, 1.49; p < 0.001). Across the entire sample, comorbid depression was also independently associated with a slightly longer length of stay (β = 0.199, 95% CI 0.155, 0.244; p < 0.001). These results provide further evidence that depression is a variable of interest in PAD and surgical quality databases should include mental health variables to enable further study.

Abstract P3-12-21: Development of peptide-based targeted α-therapy for triple negative breast cancer

Triple-negative breast cancer (TNBC) is associated with a poorer prognosis, including a higher potential to metastasize and a decrease in the 5-year survival rate as compared to other breast cancer subtypes (77% vs. 93%). The poor prognosis is partially due to the lack of targeted treatments for TNBC, highlighting the need to develop targeted therapies for TNBC. Alpha-emitting radionuclides, such as Actinium-225, provide high linear energy transfer (LET) radiation. Clinical and pre-clinical studies have shown that targeted alpha-therapy is a highly potent treatment for metastatic cancer. Peptides and peptidomimetics are minimally immunogenic and have rapid tissue and tumor penetration, and rapid clearance from non-target tissues, providing an attractive platform for targeted therapeutic agent. The RGD peptide has been shown to have a high affinity for αvβ3, which has been implicated in TNBC. The purpose of these studies is to investigate the potential of modified RGD peptide scaffolds to deliver 225Ac to triple negative breast cancer cells for targeted alpha therapy.

Methods

DOTA-cyclo-RGD(fK) and DOTA-cyclo-RGD(fK) dimer were labeled with Indium-111, a SPECT imaging surrogate for 225Ac, and Actinium-225. The resulting labeled agents were evaluated in vitro, including binding affinity assays (111In) and colony formation assays (225Ac) that are underway using the MDA-MB-231 cell line. Biodistribution experiments were performed in athymic nude mice bearing MDA-MB-231 tumors to compare the distribution and pharmacokinetics of the 111In-labeled RGD peptide scaffolds in vivo. Alpha camera imaging evaluated the microscale distribution of 225Ac-DOTA-cyclo-RGD(fK) in non-tumor bearing mice.

Results

The saturation binding assay of 111In-labeled DOTA-cyclo-RGD(fK) and DOTA-cyclo-RGD(fK) dimer demonstrated selective binding and nanomolar affinity for αvβ3. Selective targeting of αvβ3was further demonstrated in vivo for both 111In-labeled RGD agents. The 111In-labeled DOTA-cyclo-RGD(fK) demonstrated significantly higher tumor uptake at 30 minutes compared to the dimer (5.3 ± 2.9 vs. 3.0 ± 1.4 %ID/g). The 111In-DOTA-cyclo-RGD(fK) dimer was better retained in the tumor over 6 hours with significantly higher uptake at the 6-hour time point (1.2 ± 0.4 vs. 2.8 ± 1.1 %ID/g). Furthermore, the dimer had significantly higher uptake in the kidney and liver over a 6-hour window as compared to 111In-DOTA-cyclo-RGD(fK). However, both 111In-labeled RGD agents demonstrated rapid clearance from normal organs. Alpha camera images of the 225Ac-labeled dimer supported the rapid clearance from the normal tissues, with the majority of the agents being cleared within the first 90 minutes.

Conclusion

Modified RGD peptides were successfully labeled with Indium-111 and Actinium-225. The resulting agents were shown to successfully target αvβ3 selectively both in vitro and in vivo. These studies provide encouraging data to support the development and optimization of the RGD platform for αvβ3-targeted alpha therapy to treat triple negative breast cancer. Future works will investigate the therapeutic efficacy, macro- and microscale dosimetry, and toxicity of the developed 225Ac-labeled αvβ3-targeted agents as well as explore the optimization of the RGD scaffold for improved pharmacokinetics with 225Ac.

Citation Format: Nedrow JR, Cortez A, Josefsson A, Sgouros G. Development of peptide-based targeted α-therapy for triple negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-12-21.

Respiratory signs, fever and lymphopenia in calves inoculated with Brazilian HoBi-like pestiviruses

Hobi-like viruses (HobiPeV) comprise a novel, recently classified species of bovine pestiviruses, originally identified in commercial fetal bovine serum of Brazilian origin and, subsequently, isolated from diseased animals in several countries. Although frequently isolated from clinical cases, most HobiPeV isolates failed to reproduce overt disease in cattle upon experimental inoculation. Herein, we describe the outcome of experimental infection of four to six months-old seronegative calves with two Brazilian HobiPeV isolates. Calves inoculated intranasally with isolate SV478/07 developed viremia between days 2 and 9 post-inoculation (pi) and shed virus in nasal secretions up to day 11pi. These animals presented hyperthermia (day 7 to 10-11 pi) and lymphopenia from days 4 to 8pi. Clinically, all four calves developed varied degrees of apathy, anorexia, mild to moderate respiratory signs (nasal secretion, hyperemia), ocular discharge and pasty diarrhea in the days following virus inoculation. In contrast, calves inoculated with isolate SV757/15 presented only hyperthermia (days 3 to 10-11 pi) and lymphopenia (days 4-8 pi), without other apparent clinical signs. In these animals, viremia was detected up to day 9 pi and virus shedding in nasal secretions lasted up to day 12-14 pi. Both groups seroconverted to the inoculated viruses, developing virus neutralizing (VN) titers from 320 to 5120 at day 28pi. These results extend previous findings that experimental infections of calves with HobiPeV are predominantly mild, yet they also indicate that field isolates may differ in their ability to cause disease in susceptible animals.

Abstract 349: The Association of Comorbid Depression with Inpatient Outcomes in Patients with Critical Limb Ischemia

Background: Critical limb ischemia (CLI) is the end-stage of peripheral artery disease (PAD) and mounting evidence suggests an association between depression and PAD. The objective of this study was to determine whether outcomes, primarily major amputation, differed between CLI patients with and without comorbid depression in a large nationally-representative sample of patients in the United States.

Methods: Patients hospitalized for CLI during 2012 and 2013 were identified from the National Inpatient Sample (NIS) using ICD-9 diagnostic and procedure codes. Depression, revascularization procedures, and relevant comorbidities were also identified. The primary outcome was major amputation and secondary outcomes were length of stay and other complications. Multivariable logistic models were run adjusting for sociodemographic factors, prior amputation, tobacco use, and several comorbidities.

Results: The sample included 116,008 patients hospitalized for CLI of whom 10,512 (9.1%) had comorbid depression. Patients with depression were younger (64±14 yrs vs. 67±14, p<.0001) and more likely to be female (55% vs. 41%, p <.001), white (73% vs. 66%, p<.001), and tobacco users (46% vs. 41%, p<.001). They were also more likely to have prior amputations (9.8% vs. 7.9%, p<.001) and diabetes with chronic complications (25% vs. 20%, p<.001). During the hospitalization, the rate of major amputation was higher in patients with comorbid depression (11.5% vs. 9.1%, p<.001). In multivariable analysis, excluding patients who died prior to receiving an amputation (n=2,621), comorbid depression was associated with a 39% increased odds of major amputation (OR 1.39, 95%CI 1.30-1.49, p<.001). Across the entire sample, comorbid depression was also independently associated with a longer length of stay (β=0.199, 95%CI 0.155, 0.244, p<.001).

Conclusions: Comorbid depression was associated with 39% increased odds of major amputation among a large, nationally representative sample of CLI inpatients. These results provide further evidence that depression is a variable of interest in PAD and surgical quality databases should include mental health variables to enable further study of depression’s impact on surgical patients.

Influence of histological subtypes on the risk of an invasive recurrence in a large series of stage I borderline ovarian tumor including 191 conservative treatments

BACKGROUND

The overall prognosis of stage I borderline ovarian tumors (BOT) is excellent but a small percentage of patients die to their disease. The prognostic factors for such a rare event are still not clearly defined. The aim of this study was to determine these factors for recurrence per se and recurrence in the form of invasive carcinoma in a large series of stage I tumors.

METHODS

A retrospective review of patients with BOT. Three inclusion criteria were defined: (i) a centralized histological review; (ii) macroscopic stage I tumors; (iii) exclusion of metastatic disease to the ovaries.

RESULTS

From 2000 to 2010, 254 patients fulfilled inclusion criteria [140 had mucinous BOT (MBOT) and 114 a serous BOT (SBOT)], and 191 had undergone conservative management. After a median follow-up of 45 months, 43 patients had developed recurrences (31 borderline and 12 invasive). The risks of recurrences were statistically increased after conservative treatment, particularly after a cystectomy, in patients with stage IB and among patients with incompletely staged tumors. In the subgroup of conservatively treated patients (representing 75% of our population), the risks of recurrences were statistically increased in patients affected by a SBOT, in patients who had undergone a cystectomy, in patients with stage IB disease and in patients with a micropapillary pattern (MPP). MBOT and the presence of a MPP were identified as prognostic factors for invasive disease.

CONCLUSIONS

In the present series of BOT with the largest number of patients treated conservatively to date, the presence of a MPP and the mucinous subtype were associated with a higher rate of progression to carcinoma after conservative management. These important results suggest that MBOT belong to a 'high-risk' group likely to develop an invasive recurrence after fertility-sparing surgery in stage I BOT.

A clue towards improving the European Society of Medical Oncology risk group classification in apparent early stage endometrial cancer? Impact of lymphovascular space invasion

Background:

Lymphovascular space invasion (LVSI) is one of the most important predictors of nodal involvement and recurrence in early stage endometrial cancer (EC). Despite its demonstrated prognostic value, LVSI has not been incorporated into the European Society of Medical Oncology (ESMO) classification. The aim of this prospective multicentre database study is to investigate whether it may improve the accuracy of the ESMO classification in predicting the recurrence risk.

Methods:

Data of 496 patients with apparent early-stage EC who received primary surgical treatment between January 2001 and December 2012 were abstracted from prospective multicentre database. A modified ESMO classification including six risk groups was created after inclusion of the LVSI status in the ESMO classification. The primary end point was the recurrence accuracy comparison between the ESMO and the modified ESMO classifications with respect to the area under the receiver operating characteristic curve (AUC).

Results:

The recurrence rate in the whole population was 16.1%. The median follow-up and recurrence time were 31 (range: 1–152) and 27 (range: 1–134) months, respectively. Considering the ESMO modified classification, the recurrence rates were 8.2% (8 out of 98), 23.1% (15 out of 65), 25.9% (15 out of 58), and 45.1% (28 out of 62) for intermediate risk/LVSI−, intermediate risk/LVSI+, high risk/LVSI−, and high risk/LVSI+, respectively (P<0.001). In the low risk group, LVSI status was not discriminant as only 7.0% (14 out of 213) had LVSI+. The staging accuracy according to AUC criteria for ESMO and ESMO modified classifications were of 0.71 (95% CI: 0.68–0.74) and 0.74 (95% CI: 0.71–0.77), respectively.

Conclusions:

The current modified classification could be helpful to better define indications for nodal staging and adjuvant therapy, especially for patients with intermediate risk EC.

Lymphatic and nerve distribution throughout the parametrium

BACKGROUND

Our objective was to concomitantly assess distribution of lymphatic and nerve structures in the parametrium.

METHODS

Twenty hemipelvises from ten fresh cadavers were dissected to differentiate between, three different parts of the parametrium: the lateral parametrium, the proximal and the distal part of the posterior parametrium. Histologic and immunofluorescence analyses of nerve and lymphatic structures were performed using NSE and LYVE-1 staining, respectively. The percentage of structures was independently scored as 0 (0%), 1 (1-20%), 2 (20-50%), 3 (50-80%), 4 (>80%).

RESULTS

The lateral parametrium and the proximal part of the posterior parametrium contained both nerve (scored 2.25 and 2.50, respectively) and lymphatic (scored 2.50 and 2.00, respectively) structures. The distal part of the posterior parametrium also contained numerous nerve structures (scored 2.00) but lymphatic structures were rare (scored 0.88). No difference in nerve distribution was found according to the parts of parametrium while a significantly lower distribution of lymphatic vessels was observed in the distal part of the posterior parametrium (p=0.03).

CONCLUSION

The distal part of the posterior parametrium is of high nerve density and low lymphatic density raising the issue as to whether it should be removed during radical hysterectomy.

External validation of a laparoscopic-based score to evaluate resectability for patients with advanced ovarian cancer undergoing interval debulking surgery

AIM

To evaluate the relevance of laparoscopic index of Fagotti et al during staging laparoscopy (S-LPS) to predict optimal cytoreduction during interval debulking surgery (IDS) after neoadjuvant chemotherapy for ovarian cancer.

PATIENTS AND METHODS

Fifty-two patients with stage III-IV ovarian cancer were retrospectively analyzed. We evaluated discrimination with a receiver operating characteristic (ROC) curve analysis and calibration of Fagotti et al's model among our population and compared this performance with their data.

RESULTS

A score >4 was associated with optimal resection with sensitivity and positive predictive value (PPV) of 95% and 82% respectively. The ROC curve analysis gave an area under the curve (AUC) of 0.72 (95% confidence interval (CI) 0.65-0.80) for our population compared to 0.88 (95% CI 0.84-0.91) in Fagotti et al's population. Percentages predicted in our population were unsatisfactory (p<0.01), illustrating the different rates of optimal cytoreduction between the centers (average error of 25%).

CONCLUSION

The laparoscopic index of Fagotti et al is relevant in prediction of optimal cytoreduction among women undergoing IDS.

SOROPREVALÊNCIA DO VÍRUS DA INFLUENZA EQUINA NO MUNICÍPIO DE URUARÁ, PA, BRASIL, AMAZÔNIA ORIENTAL

RESUMO O objetivo do presente trabalho foi estimar a soroprevalência de anticorpos contra o vírus da influenza equina utilizando como unidades de análise os equídeos e as propriedades rurais do tipo familiar do Município de Uruará, PA. A presença de anticorpos contra o vírus da influenza equina A/Eq1/SP/56 (H7N7) e A/Eq2/SP/1/85 (H3N8) foi avaliada pela técnica de inibição da hemaglutinação (HI). O tamanho da amostra foi estimado a partir de um total de 2.069 propriedades, caracterizadas por agricultura familiar e ausência de vacinações contra qualquer enfermidade específica dos equídeos. Foi adotado o nível de confiança de 90%, com precisão de 15% e prevalência estimada de 50%. As seguintes prevalências de animais soro reagentes para os diferentes vírus foram observadas: 55,6% (45/81) (IC 49,8 a 61,3) para o vírus A/Eq1/SP/56 (H7N7) e 76,5% (62/81) (IC 70,7 a 82,3) para o vírus A/Eq2/SP/1/85 (H3N8). Todas as propriedades apresentaram pelo menos um animal soropositivo para os dois subtipos virais. Conclui-se que ambos os subtipos (H3N8 e H7N7) do vírus da influenza equina estavam circulando entre os equídeos e presentes em todas as propriedades estudadas no Município de Uruará, PA, Brasil, Amazônia Oriental, no ano de 1998.

Pulmonary morbidity of diaphragmatic surgery for stage III/IV ovarian cancer

OBJECTIVE

To determine the morbidity of diaphragmatic peritonectomy.

DESIGN

Prospective cohort study.

SETTING

A Gynecology Department of a University Hospital.

POPULATION

From 2005 to 2007, thirty-seven consecutive patients underwent surgery for stage IIIC or IV ovarian cancer.

METHODS

Patients were separated into a diaphragmatic surgery group (n = 18) and a control group (n = 19). Diaphragmatic surgery may consist of coagulation, stripping or muscle resection.

MAIN OUTCOME MEASURES

Postoperative course and outcome were analysed.

RESULTS

Patients in group 1 (diaphragmatic surgery) underwent more intestinal resection (89% versus 37%, P = 0.01) and pelvic (94% versus 63%, P = 0.02) or para-aortic lymphadenectomy (94% versus 53%, P = 0.04). Neither the mean estimated blood loss (960 ml versus 909 ml) nor the rates of intra-operative blood transfusion (11 versus 9) were significantly different between the two groups. The mean operative time was higher in group 1 (480 minutes versus 316 minutes, P < 0.05). There were thirteen postoperative complications in group 1 and eight in group 2 (P = 0.065). In group 1, the main complication was pleural effusion (seven cases): four patients required secondary pleural drainage, two required only pleural puncture and one had both procedures. There were more complete cytoreduction in group 1 than in group 2 (89% versus 63%, P = 0.068).

CONCLUSIONS

Diaphragm peritonectomies and resections are an effective way to cytoreduce diaphragm carcinomatosis and increase the rate of optimal debulking surgery. Such procedures frequently result in pleural effusion, but with no long-term morbidity.

Status of HER1 and HER2 in peritoneal, ovarian and colorectal endometriosis and ovarian endometrioid adenocarcinoma

A role for the EGF system, in particular HER1 and 2, in growth of the endometrium has been suggested but HER1 and 2 have not been studied in all locations of endometriosis and in ovarian endometrioid adenocarcinoma (OEC) which is a rare form of malignant transformation of endometriosis. Immunohistochemistry (IHC) was used for studying HER1 and HER2 in ovarian (n = 10), peritoneal (n = 10), colorectal endometriosis (n = 20) and OEC (n = 10). Fluorescent in situ hybridisation (FISH) was used for analysing the status of HER2 gene in colorectal endometriosis and OEC. All samples were negative for HER2 in both glandular and stromal cells and in glandular cells for HER1 by IHC. In 15 out of 20 colorectal endometriosis, there was a weak expression in stromal cells. Following FISH, two colorectal samples had a partial 17 aneusomy and three OEC, a 17 polysomy. The other samples were 17 disomic without HER2 amplification; HER1 and 2 do not seem to have a role in endometriosis physiopathology.

Frequency and prognostic significance of HPV DNA in sentinel lymph nodes of patients with cervical cancer

BACKGROUND

It has been suggested that histologically undetectable or 'occult' metastases in the lymphatic system could explain some recurrences. HPV DNA screening by means of the polymerase chain reaction (PCR) has been proposed as a method to detect occult metastases. This study was designed to determine the frequency of HPV DNA detection by PCR in sentinel lymph node (SN), and its relation to the clinical characteristics and outcome of women with cervical cancer.

PATIENTS AND METHODS

The primary cervical tumor and SN were tested for HPV DNA by means of PCR in 59 patients.

RESULTS

Fifteen (25.4%) of the 59 women undergoing the SN procedure had an involved SN. HPV DNA was more frequent in positive SN than in negative SN (P < 0.0001). Seven patients had a recurrence, after a mean delay of 17 months (range: 10-26). One of seven patients with a recurrence had an involved SN. HPV DNA was detected in an SN of one of seven patients with recurrence and nine (19.5%) of 46 patients without recurrence (not significant).

CONCLUSION

In women with cervical cancer, HPV DNA screening of sentinel nodes might help to identify patients at risk of lymph node metastases and recurrence.

Accuracy of transvaginal sonography and rectal endoscopic sonography in the diagnosis of deep infiltrating endometriosis

OBJECTIVES

To compare the accuracy of transvaginal sonography (TVS) and rectal endoscopic sonography (RES) for the diagnosis of deep infiltrating endometriosis (DIE), with respect to surgical and histological findings.

METHODS

This was a longitudinal study of 81 consecutive patients referred for surgical management of DIE, who underwent both TVS and RES preoperatively. The diagnostic criteria were identical for TVS and RES, and were based on visualization of hypoechoic areas in specific locations (uterosacral ligaments, vagina, rectovaginal septum and intestine). We calculated the sensitivity, specificity, predictive values and accuracy of TVS and RES for the diagnosis of DIE.

RESULTS

Endometriosis was confirmed histologically in 80/81 (98.7%) patients. Endometriomas and DIE were present in 43.2% and 97.5% of the women, respectively. For the diagnosis of DIE overall, TVS and RES, respectively, had a sensitivity of 87.3% and 74.7%, a positive predictive value of 98.6% and 98.3%, and an accuracy of 86.4% and 74%. For the diagnosis of uterosacral endometriosis, they had a sensitivity of 80.8% and 46.6%, a specificity of 75% and 50.0%, a positive predictive value of 96.7% and 89.5% and a negative predictive value of 30% and 9.3%. For the diagnosis of intestinal endometriosis, they had a sensitivity of 92.6% and 88.9%, a specificity of 100% and 92.6%, a positive predictive value of 100% and 96% and a negative predictive value of 87% and 80.6%.

CONCLUSION

TVS is apparently more accurate than is RES for predicting DIE in specific locations, and should thus be the first-line imaging technique in this setting.

The sentinel node concept in endometrial cancer: histopathologic validation by serial section and immunohistochemistry

BACKGROUND

The sentinel node (SN) is defined as the first node in the lymphatic system that drains a tumor site. If the SN is not metastatic, then all other nodes should also be disease-free. We used serial sections and immunohistochemical (IHC) staining to examine both SN and non-sentinel nodes (non-SNs).

PATIENTS AND METHODS

Twenty-three patients (median age 69 years) with early endometrial cancer underwent a laparoscopic SN procedure based on a combined detection method, followed by complete laparoscopic pelvic lymphadenectomy. If the SN was free of metastasis by both hematoxylin and eosin (H&E) and IHC staining, all non-SNs were also examined by the combined staining method.

RESULTS

SNs were identified in 19 patients (82.6%). A total of 47 SNs were removed (mean 2.5). Ten SNs (21.3%) from five patients (26.3%) were found to be metastatic at the final histologic assessment. In 14 patients, no metastatic SN involvement was detected by H&E and IHC staining. In these 14 patients, 120 non-SNs were examined by serial sectioning and IHC, and none were found to be metastatic.

CONCLUSION

The SN procedure appears to reliably predict the metastatic status of the regional lymphatic basin in patients with early endometrial cancer.

CIRCOVÍRUS SUÍNO TIPO 2 (PCV-2)

RESUMO O Circovírus suíno-2 (Porcine circovirus type 2 – PCV-2) é um vírus não envelopado, apresenta simetria icosaédrica e mede de 15 a 17 nm de diâmetro. É o menor vírus animal descrito e está relacionado a várias síndromes que acometem suínos, responsável por perdas econômicas nas granjas. A alta variabilidade da região do genoma que codifica as proteínas estruturais associada às co-infecções, dificulta o seu diagnóstico e sua prevenção.

Laparoscopic restaging of borderline ovarian tumors

BACKGROUND

This study aimed to evaluate the feasibility and relevance of laparoscopic restaging surgery for women with borderline ovarian tumors.

METHODS

From March 2001 to February 2006, 42 women referred for borderline ovarian tumors after laparoscopy or laparotomy underwent a laparoscopic restaging operation. Of these women, 37 (88%) had undergone conservative surgery including unilateral cystectomy (n = 16), bilateral cystectomy (n = 1), and unilateral salpingo-oophorectomy (n = 20). The remaining five women (12%) had undergone radical surgery, including bilateral salpingo-oophorectomy (BSO) (n = 4) and hysterectomy with BSO (n = 1). Intraoperative rupture occurred in 13 cases.

RESULTS

All 42 restaging operations were performed via the laparoscopic approach. There were no intraoperative complications, no laparoconversions, and no postoperative complications. Laparoscopic restaging identified two persistent borderline ovarian tumors (12%) in women who had initially undergone cystectomy. Seven women were upstaged (16.6%) because of positive cytology (n = 2), peritoneal biopsy (n = 2), or omentum (n = 3). Among the 28 women with initial Federation International of Gynaecology and Obstetrics (FIGO) stage Ia disease, the final stage was Ia for 24 women, Ib for 2 women, IIIa for 1 woman, and IIIc for 1 woman. Among the 12 women with initial stage Ic disease, 11 kept the same stage and 1 was upstaged to IIIc. The woman with initial stage IIa disease was upstaged to IIb, and the woman with initial stage IIc disease was upstaged to IIIc. The risk of upstaging was significantly higher among women with serous borderline tumors. Upstaging occurred in women with both initial stages I and II disease.

CONCLUSIONS

The results confirm the feasibility and safety of laparoscopic restaging operations for women with borderline ovarian tumors. Cystectomy was associated with a risk of persistent lesions. The risk of upstaging was higher for women with serous borderline ovarian tumors and women with initial FIGO stage I or II disease.

Genetic diversity of Brazilian strains of porcine circovirus type 2 (PCV-2) revealed by analysis of the cap gene (ORF-2)

Porcine circovirus 2 (PCV-2) is associated with a broad range of syndromes. In this study, 19 of 870 samples from pigs from different Brazilian states were found to be positive for PCV-2 by polymerase chain reaction (PCR). A fragment of 700 nt of the cap gene (ORF-2) from the 19 PCV-2-positive samples were sequenced using three pairs of primers (Fa/Ra, Fb/Rb and Fc/Rc). Maximum parsimony genealogy with a heuristic algorithm using the 19 field strain studied here, 21 sequences from GenBank and PCV-1 as an out-group showed the existence of two major clusters (A and B) and the Brazilian strains segregating in both of them. PCV-2 was found in pigs with various clinical signs. No association between clusters of PCV-2 and different states or clinical signs were observed, demonstrating that the exact role of PCV-2 in porcine circovirus diseases (PCVD) in Brazil still needs to be clarified. These results contribute to the molecular characterization of PCV-2, which serve as a basis for the epimiology of PCV-2 infection.

Endometrial tumor invasiveness is related to metalloproteinase 2 and tissue inhibitor of metalloproteinase 2 expressions

Matrix metalloproteinase (MMPs) expression has been linked to gynecological tumor aggressiveness. The objective of this study was to determine MMP-2, MMP-7, and MMP-9 and tissue inhibitors of metalloproteinases (TIMP)-1 and TIMP-2 expression in endometrial malignancies and their relation to clinical and histologic parameters. Formalin-fixed, paraffin-embedded tumor samples from 50 patients with endometrial carcinoma treated between 1999 and 2004 were stained with specific monoclonal antibodies. The tumors were grouped according to the FIGO classification. The staining results were compared to histologic and clinical data. Semiquantitative analysis of MMP and TIMP expression showed a significant difference in TIMP-2 expression according to the histologic subtype (P = 0.03) and also a trend towards a difference in MMP-9 expression (P = 0.05). MMP-2 expression increased and TIMP-2 expression fell as the histologic grade increased (P = 0.0007, P < 0.0001, respectively). MMP-2 expression correlated with lymph node metastasis (P = 0.04), while TIMP-2 expression correlated with the depth of myometrial invasion (P = 0.01), vasculolymphatic space involvement (P = 0.02), and lymph node metastasis (P = 0.0003). These results support the involvement of MMPs and TIMPs in endometrial tumor growth and progression. High MMP-2 and low TIMP-2 expression were the most potent markers of endometrial tumors with a high risk of local and distant spread.

Genital tract actinomycosis caused by Actimyces israëlii

We report a case of actinomycosis caused by actinomyces israelii, related to the removal of intrauterine device (IUD). Diagnosing actinomycosis is difficult but should be considered in the event of any acute abdominal problems in a woman carrying an IUD. All abdominal organs may be affected. Even with a disseminated infection, the combination of appropriate antibiotic therapy (penicillin G) and surgery ensures a full recovery in most cases.

Metalloproteinase-2, -7 and -9 and tissue inhibitor of metalloproteinase-1 and -2 expression in normal, hyperplastic and neoplastic endometrium: a clinical-pathological correlation study

BACKGROUND

Matrix metalloproteinases (MMPs) and their inhibitors are key-players in extracellular matrix and basement membrane degradation, and are involved in both physiological and malignant processes. The aim of this study was to examine MMP-2, -7 and -9 and TIMP-1 and -2 expression in normal, hyperplastic and malignant endometrium, and their relation to clinical and histological prognostic factors.

MATERIALS AND METHODS

We performed qualitative and semi-quantitative immunohistochemical analysis of 20 samples of normal endometrium (10 in the proliferative phase, 10 in the secretory phase), 39 samples of hyperplastic endometrium (17 without atypia and 22 with atypia) and 38 samples of endometrioid carcinoma, by using specific monoclonal antibodies.

RESULTS

In normal endometrium, epithelial expression of MMP-2 (P = 0.0007), MMP-7 (P = 0.0002) and TIMP-2 (P = 0.0004) was increased during the proliferative phase of the menstrual cycle. MMP-2 expression correlated negatively with TIMP-2 expression (P = 0.001, rho = 0.702). Endometrial stromal cells in the secretory phase showed strong MMP-2 expression (P = 0.004) and weak MMP-7 (P = 0.001) and TIMP-1 expression (P = 0.01). In hyperplastic endometrium, the presence of atypia was associated with lower TIMP-2 expression (P = 0.005) and was also associated with a trend towards higher MMP-2 expression. Endometrial stromal cell expression of MMP-2, -7 and -9 and TIMP-1 and -2 did not differ between hyperplastic endometrium with and without atypia. A gradient of MMP-2 and -9 expression was observed from hyperplastic endometrium to endometrial carcinomas. In endometrial carcinomas, MMP-2 expression increased (P = 0.0004) and TIMP-2 expression decreased (P = 0.0005) with the histological grade. TIMP-2 expression correlated with myometrial invasion (P = 0.005), lymphovascular space involvement (P = 0.008) and lymph node involvement (P = 0.007).

CONCLUSION

These results support the involvement of MMPs and TIMPs in endometrial carcinogenesis. Strong MMP-2 and weak TIMP-2 expression were the most potent markers of endometrial malignancies with a high risk of local and distant spread.

Immunohistochemistry of adhesion molecules, metalloproteinases and NO-synthases in extravillous trophoblast of tubal pregnancy

Trophoblast invasion in uterine pregnancy is fine-tuned for the remodelling of the uterine wall and its vascularization. Tubal pregnancy, which occurs in a limited number of patients, involves a dramatic trophoblast invasion in a context of a poor decidualization. By studying the histology of the extravillous trophoblast (EVC) in the anchoring villi, the Ki67 labelling, the location of several adhesion markers (cytokeratin-7, alpha1, alpha6, alphaV, beta1, beta4 integrin subunits and E-cadherin, V/E-cadherin), metalloproteinases (MMP-2, 9 and11), NOS2 and 3, we aimed to detect the specificity of tubal compared to intrauterine pregnancies. No difference could be observed between meso or anti-salpingial trophoblast proliferation or invasion using Ki67. Cytokeratin-7 allowed detection of spindle-shape EVCs and we identified some decidualized stromal cells. Integrins alpha1, beta1 and alphaV, and V/E-cadherin were expressed mainly in the distal EVC correspondingly to intrauterine pregnancy, with a poor expression of alpha1. Integrins alpha6 and beta4, E-cadherin were detected in the distal EVC in contrast to uterine pregnancy. MMP-2, 9, 11 were also shown in distal EVC. NOS2 and 3 labelled the perivascular EVC and NOS3 the endothelial cells of the tubal vessels. These changed distributions of adhesion molecules and MMP together with that of the basic and inducible NOS expressions could be related to mechanical effects in superficial implantation or to a failure of decidualization in tubal pregnancies.

Immunocytological evidence for hematopoiesis in the early human placenta

Hematopoiesis has previously been observed in the human yolk sac, in placental villi and in the embryonic aorta. Here, our immunocytological study at 24 and 35 days showed packed erythroblasts in the placental vessels, mitotic figures and anti-Ki-67 reactions within these cells. Morphologically, the erythroblasts and vessels were similar to those found in the yolk sac during primitive hematopoiesis. In addition, numerous extravascular erythroblasts were found in the villous core. Positive reactions were obtained in erythroblasts using antibodies against glycophorin-A, GATA-2 and C-kit that characterize the hematopoietic cells. However, erythroblasts did not react with anti-CD34 and anti-CD45. In this respect, they differ from the hematopoietic cell clusters observed in the aorta of the human embryo. The staining for glycophorin-A was maintained in erythroblasts at 6-7 weeks and 12-14 weeks. Anti-GATA-2 reaction was decreased in erythroblasts and appeared in the perivillous cytotrophoblast. Anti-C-kit signal was detected in endothelial cells at 6-7 weeks and switched to stromal and perivascular cells at 12-14 weeks. By term, anti-GATA-2 staining was still present in the trophoblast and appeared in vessels while anti-C-kit was negative. For the leukocytes marker CD15, a staining was found in the endothelium at 35 days, 6-7 and 12-14 weeks and in leukocytes at term. CD45 antibody decorated the leukocytes at 12-14 weeks and at term. Erythroblasts undergo a primitive hematopoiesis in the early placental vessels that may be of value for the embryo in a period of low oxygen environment.

Sentinel node biopsy is reliable in early-stage cervical cancer but not in locally advanced disease

BACKGROUND

Sentinel lymph node (SN) biopsy based on dual labeling with blue dye and radiocolloid can reliably determine lymph node status in early-stage cervical cancer, but few data are available on its accuracy in more advanced disease. We examined the influence of tumor stage on the accuracy of SN biopsy in patients with cervical cancer.

METHODS

Between July 2001 and June 2004, 33 patients (mean age 52 years) with early-stage or locally advanced cervical cancer underwent laparoscopic SN biopsy based on dual labeling with patent blue and radiocolloid. Patients with early-stage cervical cancer (stages IA and IB1, 23 patients) underwent complete laparoscopic pelvic lymphadenectomy after the SN procedure. Patients with locally advanced cervical cancer (stage IB2, IIA or IIB, 10 patients) underwent laparoscopic pelvic and para-aortic lymphadenectomy after SN biopsy and prior neoadjuvant concomitant chemoradiotherapy. The SN identification rates and false-negative rates of patients with early-stage and locally advanced disease were compared.

RESULTS

The mean numbers of SNs identified per patient with early-stage and locally advanced cervical cancer were 2.3 (range 0-4) and 1.9 (range 0-4), respectively. SNs were identified in 86.9% (20/23) of patients with early-stage disease and in 80% (8/10) of patients with locally advanced disease. When analyzed according to the side of dissection, the identification rate was lower, especially in the patients with locally advanced disease (55% compared with 67.4%). The false-negative rate per patient was zero in early-stage disease and 20% (1/5) in locally advanced disease (no significant difference). When the side of dissection was taken into account, the false-negative rate improved to 42.9% (3/7) in patients with locally advanced disease and remained at zero in early-stage disease (P=0.038). Isolated blue dye was taken up in 53.3% of SNs in patients with locally advanced disease, compared with only 6.4% in patients with early-stage disease.

CONCLUSIONS

This study suggests that the SN biopsy technique with dual labeling is less accurate in locally advanced cervical cancer than in early-stage cervical cancer.

DETECÇÃO DOS GENES DAS TOXINAS ALFA (α), BETA (β) E ÉPSILON (ε) EM AMOSTRAS DE CLOSTRIDIUM PERFRINGENS ISOLADAS DE BOVINOS PELA REAÇÃO EM CADEIA DA POLIMERASE (PCR)

RESUMO O Clostridium perfringens, microrganismo anaeróbio, está presente no solo e no trato intestinal dos mamíferos. Provoca gangrena gasosa e intoxicação alimentar nos seres humanos e doenças enterotoxêmicas nos animais domésticos. O C. perfringens é classificado em 5 tipos (A, B, C, D e E) mediante a produção de quatro toxinas principais (alfa-α, beta-β, gama-γ, delta-δ e épsilon-ε). A identificação destas toxinas é realizada através da reação de soroneutralização em animais utilizando anti-soros específicos, os quais, além do alto custo, são de difícil obtenção em laboratórios de referência internacionais. Visando contribuir para a tipificação de amostras de C. perfringens, em nosso meio, o presente trabalho teve como objetivo avaliar a reação em cadeia da polimerase (PCR) na detecção dos genes que codificam as toxinas alfa (cpa), beta (cpb) e épsilon (etx) em isolamentos provenientes de bovinos. A sensibilidade analítica da técnica de PCR padronizada a partir do DNA total bacteriano foi de 2,27 ng/?L para o gene cpa e 227 pg/?L para os genes cpb e etx. Das 35 amostras de C. perfringens isoladas e tipificadas por PCR, 16 (45,7%) foram do tipo A, 18 (51,4%) foram do tipo C e 1 (2,9%) foi do tipo B.

Rickettsia felis (Rickettsiales: Rickettsiaceae) in Ctenocephalides felis felis (Siphonaptera: Pulicidae) in the State of São Paulo, Brazil

Samples of 10 and 14 Ctenocephalides felis felis fleas were collected on dogs from Pedreira and Mogi das Cruzes municipalities, respectively, in the State of São Paulo, Brazil, for detection of Rickettsia spp. Individual fleas were submitted to Polymerase Chain Reaction targeting the 17-kDa and the 190-kDa (OmpA) genes of Rickettsiae. This later gene is specific for spotted fever group. Nine fleas from Pedreira (90%) and four fleas from Mogi das Cruzes (28%) were positive for the 17-kDa gene, and eight fleas from Pedreira (80%) and four from Mogi das Cruzes (28%) were positive for 190-kDa gene. The nucleotide sequence of the 190-kDa products of one flea from Pedreira and one flea from Mogi das Cruzes were 100% identical to each other, and when compared to the GenBank Data, they were 100% identical to the 190-kDa sequence of R. felis. This was the first report of its occurrence in the State of São Paulo.

Valeurs diagnostiques de l’échographie et de l’IRM pour l’évaluation de l’endométriose pelvienne profonde

Deep pelvic endometriosis may involve the uterosacral ligaments, cul-de-sac of Douglas, vagina, rectum, and occasionally the bladder. Evaluation by physical examination is difficult, and imaging techniques are needed to evaluate the location and extent of endometriosis. In this review, we review the transvaginal and transrectal sonographic and MR imaging features suggestive of deep pelvic endometriosis and their diagnostic value.

The heminested RT-PCR for the study of rabies virus pathogenesis

The aim of the present trial was to evaluate the heminested RT-PCR for the study of rabies virus distribution in mice inoculated experimentally. Inoculation was by the intramuscular route in 150 mice, using the dog street rabies virus. Groups of five animals were killed at different times. Fragments of different organs were collected and the material was tested by Fluorescent Antibody Test (FAT) and heminested RT-PCR (hn RT-PCR). Positive results were obtained beginning on the 10th day after inoculation in the brain, spinal cord, salivary gland, limbs, lungs, liver, spleen, urinary bladder, tongue and right kidney. Hn RT-PCR was shown to be more efficient for the study of rabies virus distribution in different tissues and organs.

POSITIVE PCR FOR LEPTOSPIRA SPP. IN A SOW FROM A GERMAN HERD PRESENTING ANIMALS WITH MAT TITRES FOR LEPTOSPIRA INTERROGANS SEROVAR BRATISLAVA

ABSTRACT Reports based on serological data indicate Leptospira (L.) interrogans serovar Bratislava infection in pigs in parts of Germany and other countries. Two sows of a pig breeding herd located in Germany and which showed titres of 200 and 800 against L. interrogans serovar Bratislava in MAT were followed up under experimental conditions with microbiological and PCR methods for detection of leptospires. Cultures of urine and organs were negative for leptospires in both pigs. The PCR was also negative in all samples of one pig, but was positive in samples from uterus, oviduct and ovary of the other animal. The histological investigation of the kidneys from this pig showed an interstitial glomerulonephritis. The positive results of the PCR demonstrated the tropism of leptospires for the genital tract. This fact may be responsible for more unexpected abortion and infertility in pig breeding herds.