A New Frontier for Drug-Coated Balloons: Treatment of "De Novo" Stenosis in Large Vessel Coronary Artery Disease

Background: Drug-coated balloons (DCB) are a well-established option for treating in-stent restenosis endorsed by European Guidelines on myocardial revascularization. However, in recent years, a strategy of "leaving nothing behind" with DCB in de novo coronary stenosis has emerged as an appealing approach. Methods: We performed a systematic review to evaluate the current literature on the use of drug-coated balloons in the treatment of de novo stenosis in large vessel disease. Results: Observational studies, as well as randomized studies, demonstrated the safety of DCB percutaneous coronary interventions (PCI) in large vessel disease. The rate of major adverse cardiac events is even lower compared to drug-eluting stents in stable coronary artery disease. Conclusions: DCB PCI is feasible in large vessel disease, and future large, randomized studies are ongoing to confirm these results.

Risk stratification in transthyretin-related cardiac amyloidosis

Transthyretin related cardiac amyloidosis (TTR-CA) is an infiltrative cardiomyopathy that cause heart failure with preserved ejection fraction, mainly in aging people. Due to the introduction of a non invasive diagnostic algorithm, this disease, previously considered to be rare, is increasingly recognized. The natural history of TTR-CA includes two different stages: a presymptomatic and a symptomatic stage. Due to the availability of new disease-modifying therapies, the need to reach a diagnosis in the first stage has become impelling. While in variant TTR-CA an early identification of the disease may be obtained with a genetic screening in proband's relatives, in the wild-type form it represents a challenging issue. Once the diagnosis has been made, in order to identifying patients with a higher risk of cardiovascular events and death it is necessary to focus on risk stratification. Two prognostic scores have been proposed both based on biomarkers and laboratory findings. However, a multiparametric approach combining information from electrocardiogram, echocardiogram, cardiopulmonary exercise test and cardiac magnetic resonance may be warranted for a more comprehensive risk prediction. In this review, we aim at evaluating a step by step risk stratification, providing a clinical diagnostic and prognostic approach for the management of patients with TTR-CA.

New molecular markers for the evaluation of gamete quality

PURPOSE

Only 30 % of IVF cycles result in a pregnancy, so that multiple embryos need to be replaced, per treatment cycle, to increase pregnancy rates, resulting in a multiple gestation rate of 25 %. The use of new markers in the gamete selection, could reduce the number of the oocytes to be fertilized and embryos to be produced, but the tools to evidence the gamete competence remain unavailable and more studies are needed to identify bio-markers to select the best oocyte and sperm to produce embryos with higher implantation potentiality.

METHODS

To define oocyte competence, the apoptosis of the surrounding cumulus cells and the oxygen consumption rates for individual oocytes before fertilization seems to provide a non-invasive marker of oocyte competence and hence a quantitative assessment of the reproductive potential for the oocyte. The chromatin integrity seems to be used also as biological marker of sperm competence, together with the morphological evaluation of large vacuoles in the head.

RESULTS

The apoptosis rate of cumulus cells lower than 25 % and an higher oxygen consumption could be an evidence of an overall metabolic activity, related to a better fertilization ability and embryo cleavage quality. The apoptosis rate of the sperm chromatin, evaluated by direct Tunel in situ analysis, seems to be, also for the male gamete, a marker of competence and implantation potentiality, in particular when it is lower than 20 %. The evaluation of the presence of large vacuoles in the sperm head prior to perform ICSI seems to increase the implantation rate, but it is not associated to chromatin integrity.

CONCLUSIONS

The biological concept of competence appears unrelated to any morphological parameters, so that it is necessary to investigate new molecular markers in the gamete selection. Apoptosis of cumulus cells in the oocytes and spermatozoa, revealing the presence of large vacuoles, could help to determine the competence of the gamete to be fertilize.

Unilateral photophobia or phonophobia in migraine compared with trigeminal autonomic cephalalgias

Our objective was to compare the presence of self-reported unilateral photophobia or phonophobia, or both, during headache attacks comparing patients with trigeminal autonomic cephalalgias (TACs)--including cluster headache, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and paroxysmal hemicrania--or hemicrania continua, and other headache types. We conducted a prospective study in patients attending a referral out-patient clinic over 5 months and those admitted for an intramuscular indomethacin test. Two hundred and six patients were included. In episodic migraine patients, two of 54 (4%) reported unilateral photophobia or phonophobia, or both. In chronic migraine patients, six of 48 (13%) complained of unilateral photophobia or phonophobia, or both, whereas none of the 24 patients with medication-overuse headache reported these unilateral symptoms, although these patients all had clinical symptoms suggesting the diagnosis of migraine. Only three of 22 patients (14%) suffering from new daily persistent headache (NDPH) experienced unilateral photophobia or phonophobia. In chronic cluster headache 10 of 21 patients (48%) had unilateral photophobia or phonophobia, or both, and this symptom appeared in four of five patients (80%) with episodic cluster headache. Unilateral photophobia or phonophobia, or both, were reported by six of 11 patients (55%) with hemicrania continua, five of nine (56%) with SUNCT, and four of six (67%) with chronic paroxysmal hemicrania. Unilateral phonophobia or photophobia, or both, are more frequent in TACs and hemicrania continua than in migraine and NDPH. The presence of these unilateral symptoms may be clinically useful in the differential diagnosis of primary headaches.

Psychiatric side effects during methysergide treatment

A patient is reported with psychological change characterised by impaired concentration and thought projection, followed by both severe anxiety and depression, starting after three weeks on high dose methysergide. The acute problem settled slowly after methysergide withdrawal and is likely to represent an unusual and serious side effect of that drug.

Age and homocysteine plasma levels are risk factors for thrombotic complications after ovarian stimulation

BACKGROUND

The magnitude of thrombotic risk during ovarian stimulation cycles is not known. We calculated the magnitude of thrombotic risk in a cohort of women starting a new cycle of ovarian stimulation and investigated the role of inherited and acquired thrombophilia for these events.

METHODS

This is an observational study involving outpatients of a clinical research centre. Consecutive women undergoing ovarian stimulation (n = 305) were enrolled. Blood samples for studying inherited and acquired thrombophilia were obtained > or = 2 months after the last cycle of treatment. Odds ratios (OR) and confidence intervals (CI) were determined for markers significantly associated with thrombotic events. Blood samples were analysed for inherited and acquired causes of thrombophilia (antithrombin, protein C, protein S, antiphospholipid antibodies, the Factor V Leiden and FIIA20210 mutations, the TT677 MTHFR genotype, and homocysteine plasma levels).

RESULTS

Thrombotic events were observed in 4/747 cycles of ovarian stimulation, with a prevalence of 0.5%, corresponding to 1.6 per 100 000 cycles/woman. Age > or = 39 years and homocysteine plasma levels above the 97.5 percentile were significantly associated with thrombotic events during IVF [OR 15.2 (95% CI 2.0-115.0) and 14.4 (1.5-141.3) respectively].

CONCLUSIONS

Age > or = 39 years and mild hyperhomocysteinaemia are strongly associated with the occurrence of thrombotic events during IVF.

Ovarian function following radiation and chemotherapy for cancer

High-dose chemotherapy and radiotherapy have increased the long-term survival of young patients with cancer; nevertheless, the toxic effects on ovarian function causing amenorrhoea, premature menopause and infertility, are still severe.

Total laparoscopic hysterectomy versus total abdominal hysterectomy: an assessment of the learning curve in a prospective randomized study

The present randomized study was undertaken in order to compare the short-term results between total laparoscopic hysterectomy and abdominal hysterectomy in a centre with experience in laparoscopic surgery. From January 1997 to September 1998 inclusive, 102 women aged 44-71 years were randomly assigned to either total laparoscopic hysterectomy (n = 51 patients) or abdominal hysterectomy (n = 51 patients). The patients' demographic characteristics were similar in both groups. Average intra-operative blood loss was lower in laparoscopic hysterectomy than in abdominal hysterectomy (P </= 0. 001). The average time employed for laparoscopic hysterectomy was 104.1 +/- 26.98 min; according to the learning curve experienced in this study, the range was 72-163 min and the results after the plateau was reached showed no statistical difference between laparoscopic and abdominal operating times. The mean length of hospital stay was 2.38 +/- 0.30 days in the laparoscopic hysterectomy group versus 6.23 +/- 1.85 days in the abdominal hysterectomy group (P </= 0.001). In conclusion, this study shows that total laparoscopic hysterectomy can be effectively performed within reasonable time limits, provided that operators are experienced surgeons in operative laparoscopy and that operating times are comparable with those of abdominal hysterectomy.

Endoscopic management of a case of 'complete septate uterus with unilateral haematometra'

Endoscopy and ultrasound was used to diagnose a 13 year old virgin girl who presented with dysmenorrhoea and suspected right side adnexal tumescence. The girl was found to have a complete septate uterus with non-communicating right hemicavity and haematometra, an exceptional type of Müllerian anomaly. After pretreatment with buserelin, hysteroscopic metroplasty was successfully performed.

Activation of the acrosome reaction after treatment with human follicular fluid. A morphofunctional evaluation useful for in vitro fertilization

Studies aided by transmission electron microscopy were made in order to evaluate the occurrence and efficiency of the human follicular fluid in the activation of the processes leading to the acrosome reaction; quantitative, qualitative and morphological data and relative evaluations are here presented. The effects of the human follicular fluid were compared with those determined by other types of treatment, semen untreated, Pellet-Swim-up, and Centrifugation on Discontinuous Percoll Gradient. The transmission electron microscope observations permitted to evaluate the percentage of sperm with an activation of the acrosome reaction in the different groups. The analysis of the data showed a statistically relevant difference (P < 0.001) among the first group (Control group) and the SU group, the MP group and the hFF group, regarding the sperm with AR activation. The sperm treatment with 50% diluted hFF represents an important option to the preparation protocols of the semen samples useful for ART.

Assisted conception and immunological infertility

Our work with a group involved in Assisted Conception (AC) has provided us with a perfect opportunity for making an assessment of the efficiency of the techniques used for the treatment of Male Antisperm Autoimmunization (MAA) and Female Antisperm Isoimmunization (FAI). The aim of this study is to present all the most important methods of AC used by our group for the treatment of immunological infertility, such as intrauterine insemination, intraperitoneal insemination, intrafallopian gamete transfer, in-vitro insemination and intrauterine embryo transfer, intrafallopian zygote transfer, intrafallopian embryo transfer, and gamete micromanipulation. In-vitro fecundation would appear to be particularly efficient in cases of FAI, while MAA would seem to benefit more from the use of gamete micromanipulation.

Computer-assisted assessment of the variations of sperm kinetics after semen treatment with Pellet Swim-up (PSu), and with centrifugation on a discontinuous Percoll gradient at reduced volumes (mini-CDPG)

The semen of the male partners of 37 infertile couples was analyzed with the use of the HTM-S Motility Analyzer (HTM-S MA). For each sample it was thus possible to assess the Total Concentration (TC), the Motile Cell Population Concentration (MCPC), the Progressive Cell Population Concentration (PCPC), the Average Path Velocity (VAP), the Straight Line Velocity (VSL), the Curvilinear Velocity (VCL), the Straightness (STR), the Linearity (LIN), the Lateral Head Displacement (ALH) and the Head Size (HS). The same parameters were then measured on the same semen after treatment with the Pellet Swim-up (PSu) and following Centrifugation on reduced-volume Discontinuous Percoll gradient (mini-CDPG). There was a significant difference in the TC (51.63 M/ml +/- 43.99 in the untreated ejaculate, 11.48 M/ml +/- 9.66 after PSu, 7.94 M/ml +/- 7.3 after mini-CDPG; chi r2 = 50.392, p < 0.05), in the MCPC (20.95 M/ml +/- 26.29 in the untreated ejaculate, 3.79 M/ml +/- 4.26 after PSu, and 2.74 M/ml +/- 3.73 after mini-CDPG; chi r2 = 33.55, p < 0.05), and in the PCPC (7.8 M/ml +/- 12.87 in the untreated ejaculate, 1.81 M/ml +/- 2.36 after PSu, and 1.28 M/ml +/- 1.73 after min-CDPG; chi r2 = 6.38; p < 0.05). The overall comparison between the couples showed a significant difference in the MCPC after PSu and after mini-CDPG (z = -2.09, p < 0.05) whereas no significant difference was found in the comparison off the results of either the TC after PSu and after mini-CDPG (z = -1.9; NS), or of the PCPC after PSu and after mini-CDPG (z = -1.68; NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Advantages of treatment with human follicular fluid in the management of severely dyspermic patients in human in vitro fertilization programs

In 26 couples undergoing in-vitro fertilization and embryo transfer (IVF/ET), where the male partner was severely dyspermic, the seminal fluid was treated with Pellet Swim-up (PSu), modified by a 20-minute sperm incubation period in non-decomplemented human follicular fluid (hFF) diluted to 50%. In another group of 26 severely dyspermic couples undergoing IVF/ET, the semen was treated with a variant of centrifugation on discontinuous Percoll gradients (CDPG), called mini-CDPG. Pre-treatment with hFF produced a significant increase in oocyte fertilization rate (46.8% in the hFF group compared with 18.4% in the mini-CDPG couples; Kolmogorov-Smirnov Test: D = 0.5, p < 0.01), in the transfer rate per patient (96.1% in the hFF group and 50% in the mini-CDPG group; (Chi-square Test: x2 = 11.827, p < 0.001), and in the pregnancy rate per patient (respectively of 26.9% and 0%; Fisher's exact probability test: P = 0.0049, p < 0.01). There was a high miscarriage rate in the pregnancies obtained in the hFF group (42.8%). The results might be linked to a positive effect of the hFF on sperm capacity and on acrosome reaction. The Authors conclude that the use of hFF would seem to be an extremely useful treatment of the semen of severely dyspermic patients in assisted fertilization programs.

Initial experience of a new linear everting falloposcopy system in comparison with hysterosalpingography

OBJECTIVE

To assess the endolumenal portion of the fallopian tube from ostium to fimbria using a specially designed linear everting catheter and microendoscope. The study compared falloposcopy results with those obtained with hysterosalpingography (HSG) in the same patients and explored the system's ability to classify internal tubal conditions.

DESIGN

A prospective study of a new diagnostic technique, falloposcopy, versus conventional means of evaluating tubal status.

SETTING

A tertiary university infertility center.

PATIENTS

Eighteen infertile patients with a previous history of infertility of at least 2 years duration.

INTERVENTION

Diagnostic falloposcopy was performed on a total of 31 tubes.

RESULTS

Although the results of HSG and falloposcopy were in agreement in 19 cases, falloposcopy findings were at significant variance with HSG in 12 cases (40%). Seventeen of the tubes visualized by falloposcopy were considered to be normal, 10 showed mild disease, and 4 were severely damaged.

CONCLUSION

Falloposcopy using the linear everting catheter is rapid and atraumatic. It provides more complete information concerning tubal status than HSG and as such constitutes an important advance in diagnosis and therapy planning.

Role of leuprolide acetate depot in hysteroscopic surgery: a controlled study

OBJECTIVE

To evaluate leuprolide acetate (LA) depot (Enantone Depot, Takeda, Italy) when administered preoperatively in hysteroscopic surgery.

DESIGN

Prospective, comparative study.

SETTING

University Clinic of Obstetrics and Gynecology.

PATIENTS

One hundred ninety-three patients (114 pretreated with LA depot and 79 controls) who underwent hysteroscopic surgery for uterine septa (group A), submucous fibroids (group B), and abnormal uterine bleeding (group C).

RESULTS

In groups B and C there was a significant reduction in the operating time, bleeding during the operation, and the amount of distention medium required after LA depot administration, but no significant differences in surgical feasibility or efficacy were found in group A patients after treatment.

CONCLUSION

Preoperative treatment with LA depot is effective in making hysteroscopic surgery easier.

Evaluation of the importance of Chlamydia T. and/or Mycoplasma H. and/or Ureaplasma U. genital infections and of antisperm antibodies in couples affected by muco-semen incompatibility and in couples with unexplained infertility

Both the male and female partners of 28 couples with muco-semen incompatibility and of 8 couples with unexplained infertility were examined for the presence of genital infections by Chlamydia T. and/or Mycoplasma H. and/or Ureaplasma U. (CMU infections), and for topical and serum antisperm antibodies (AS-abs). The presence of other common genital infections, and for Candida A. and Trichomonas had previously been excluded in all the subjects; all the female partners presented normal hysterosalpingographs, regular ovulatory function and cervical score > or = 10. The main cause of the muco-semen incompatibility was dysspermia (35.7%), either associated or not with male CMU infections, followed by female CMU infections (21.4%), male CMU infections without dysspermia (3.6%), and the presence of AS-abs in the mucus (3.6%) and in the semen (3.6%); in 32.6% of the cases no plausible explanation was found for muco-semen incompatibility. In 42.8% CMU infections were implicated in the muco-semen incompatibility; furthermore, there was associated dysspermia in 50% of the cases. AS-abs were found in the mucus or in the serum of 70% of the patients with CMU infections, while this figure went down to 34.6% in subjects not affected by such infections. None of the patients with CMU infections showed AS-abs either in the semen and/or in the serum. AS-abs were found in the serum of 25% of the female patients with so-called "unexplained" infertility. CMU infections are important for the determination of muco-semen incompatibility, both with and without dyspermia.(ABSTRACT TRUNCATED AT 250 WORDS)

Assisted fertilization with epididymal spermatozoa

In vitro fertilization is used for several years as a technique for resolving infertility problems due to moderate or severe oligospermia. More recently, techniques of micro-insemination of oocytes have also become available for cases of extremely severe oligospermia which cannot be resolved by classical I.V.F. Nevertheless, although these particular techniques have already led to results which have gone far beyond initial hopes, they are not able to resolve all cases of male sterility. There are indeed many situations of excretory azoospermia associated with normal spermatogenesis; the spermatozoa remain trapped in a more or less extensive part of the epididymis because its passage is blocked, either because of post-infectious sclerosis, or of agenesis of a variably extensive area of the Wolffian duct. Post-inflammatory occlusions can be treated by micro-surgery, whereas in cases of agenesis, attempts to collect spermatozoa by means of an artificial spermatocele have led to far too many failures, and this technique has now been abandoned, in spite of some successful pregnancies. The extraordinary development of in vitro fertilization techniques has led to the logical idea that it might be possible to collect epididymal spermatozoa for oocyte fertilization.

Assisted reproductive technologies in severe male infertility

The increasing incidence of male subfertility as an indication for ART is first discussed. The tendency to use assisted reproduction techniques in such cases is attributed to the disappointing results of classical treatments. The Authors deal with two problems: the choice of the best treatment methods of the sperm and the choice of the best technique of ART for treating male infertility. The analysis of 138 couples treated for male subfertility showed that the centrifugation on discontinuous Percoll gradients (CDPG) and especially on the mini-Percoll (mini CDPG) offers the best results if compared with pellet swim up and other techniques. With reference to the technique of choice, an accurate analysis of tubal (TET and ZIFT) and uterine (IVF/ET) transfers shows that no advantage seems to be obtained with the more sophisticated and exacting tubal transfer. This final conclusion is presently evaluated on the basis of a retrospective study.

Heterotopic pregnancy associated with gamete intra-fallopian transfer

Recent reports in the literature have focused on the increased risk of heterotopic pregnancy after the transfer of multiple concepti or oocytes. In an international collaborative patient registry between 1985 and 1989, 601 clinical pregnancies resulted from 2092 gamete intra-Fallopian transfer (GIFT) retrieval cycles. Five of the pregnancies were heterotopic (0.83%). After surgical intervention, all five cases of combined gestation resulted in live birth from intrauterine pregnancies. Routine vaginal ultrasonographic examination of the adnexa in patients who conceive after GIFT may help early diagnosis of heterotopic pregnancy. If the diagnosis is made early, conservative treatment may preserve the future fecundity of the patient and more intrauterine pregnancies may be salvaged.

Successful pregnancy in a pure gonadal dysgenesis with karyotype 46,XY patient (Swyer's syndrome) following oocyte donation and hormonal treatment

A pregnancy obtained in a patient with 46XY gonadal dysgenesis (Swyer's syndrome) after ovum donation and IVF/ET is described. The efficacy of this technique in overcoming particular cases of otherwise irreversible infertility is discussed.

Thanatophoric dysplasia in monozygotic twins discordant for cloverleaf skull: prenatal diagnosis, clinical and pathological findings

We present male monozygotic twins with thanatophoric dysplasia (TD) type I concordant for long bone abnormalities and discordant for cloverleaf skull. The twins were the product of the second pregnancy of unrelated parents, with advanced paternal age. Prenatal diagnosis and postmortem examination showed severe rhizomelic shortness of limbs, bowing of the long bones with "telephone-receiver" femora in both twins, and cloverleaf skull and hydrocephalus in one of them. It is now accepted that most of cases of TD, such as in the present report, represent an autosomal dominant mutation with a high new mutations rate.