Third-trimester ultrasound for antenatal diagnosis of placenta accreta spectrum in women with placenta previa: results from the ADoPAD study

OBJECTIVE

To evaluate the performance of third-trimester ultrasound for the diagnosis of clinically significant placenta accreta spectrum disorder (PAS) in women with low-lying placenta or placenta previa.

METHODS

This was a prospective multicenter study of pregnant women aged ≥ 18 years who were diagnosed with low-lying placenta (< 20 mm from the internal cervical os) or placenta previa (covering the internal cervical os) on ultrasound at ≥ 26 + 0 weeks' gestation, between October 2014 and January 2019. Ultrasound suspicion of PAS was raised in the presence of at least one of these signs on grayscale ultrasound: (1) obliteration of the hypoechogenic space between the uterus and the placenta; (2) interruption of the hyperechogenic interface between the uterine serosa and the bladder wall; (3) abnormal placental lacunae. Histopathological examinations were performed according to a predefined protocol, with pathologists blinded to the ultrasound findings. To assess the ability of ultrasound to detect clinically significant PAS, a composite outcome comprising the need for active management at delivery and histopathological confirmation of PAS was considered the reference standard. PAS was considered to be clinically significant if, in addition to histological confirmation, at least one of these procedures was carried out after delivery: use of hemostatic intrauterine balloon, compressive uterine suture, peripartum hysterectomy, uterine/hypogastric artery ligation or uterine artery embolization. The diagnostic performance of each ultrasound sign for clinically significant PAS was evaluated in all women and in the subgroup who had at least one previous Cesarean section and anterior placenta. Post-test probability was assessed using Fagan nomograms.

RESULTS

A total of 568 women underwent transabdominal and transvaginal ultrasound examinations during the study period. Of these, 95 delivered in local hospitals, and placental pathology according to the study protocol was therefore not available. Among the 473 women for whom placental pathology was available, clinically significant PAS was diagnosed in 99 (21%), comprising 36 cases of placenta accreta, 19 of placenta increta and 44 of placenta percreta. The median gestational age at the time of ultrasound assessment was 31.4 (interquartile range, 28.6-34.4) weeks. A normal hypoechogenic space between the uterus and the placenta reduced the post-test probability of clinically significant PAS from 21% to 5% in women with low-lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 9% in the subgroup with previous Cesarean section and anterior placenta. The absence of placental lacunae reduced the post-test probability of clinically significant PAS from 21% to 9% in women with low-lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 36% in the subgroup with previous Cesarean section and anterior placenta. When abnormal placental lacunae were seen on ultrasound, the post-test probability of clinically significant PAS increased from 21% to 59% in the whole cohort and from 62% to 78% in the subgroup with previous Cesarean section and anterior placenta. An interrupted hyperechogenic interface between the uterine serosa and bladder wall increased the post-test probability for clinically significant PAS from 21% to 85% in women with low-lying placenta or placenta previa and from 62% to 88% in the subgroup with previous Cesarean section and anterior placenta. When all three sonographic markers were present, the post-test probability for clinically significant PAS increased from 21% to 89% in the whole cohort and from 62% to 92% in the subgroup with previous Cesarean section and anterior placenta.

CONCLUSIONS

Grayscale ultrasound has good diagnostic performance to identify pregnancies at low risk of PAS in a high-risk population of women with low-lying placenta or placenta previa. Ultrasound may be safely used to guide management decisions and concentrate resources on patients with higher risk of clinically significant PAS. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Intracervical lakes as sonographic marker of placenta accreta spectrum disorder in patients with placenta previa or low-lying placenta

OBJECTIVE

To evaluate the diagnostic accuracy of a new ultrasound sign, intracervical lakes (ICL), in predicting the presence of placenta accreta spectrum (PAS) disorder and delivery outcome in patients with placenta previa or low-lying placenta.

METHODS

This was a retrospective multicenter study of women with placenta previa or low-lying placenta at ≥ 26 weeks' gestation, who were referred to three Italian tertiary units from January 2015 to September 2018. The presence of ICL, defined as tortuous anechoic spaces within the cervix which appeared to be hypervascular on color Doppler, was evaluated on ultrasound images obtained at the time of referral. The primary aim was to explore the diagnostic accuracy of ICL in detecting the presence and depth of PAS disorder. The secondary aim was to explore the accuracy of this sign in predicting total estimated blood loss, antepartum bleeding, major postpartum hemorrhage at the time of Cesarean section and need for Cesarean hysterectomy. The diagnostic accuracy of ICL in combination with typical sonographic signs of PAS disorder, was assessed by computing summary estimates of sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios and diagnostic odds ratios (DOR).

RESULTS

A total of 332 women with placenta previa or low-lying placenta were included in the analysis, with a median maternal age of 33.0 (interquartile range, 29.0-37.0) years. ICL were noted in 15.1% of patients. On logistic regression analysis, the presence of ICL was associated independently with major postpartum hemorrhage (odds ratio (OR), 3.3 (95% CI, 1.6-6.5); P < 0.001), Cesarean hysterectomy (OR, 7.0 (95% CI, 2.1-23.9); P < 0.001) and placenta percreta (OR, 2.8 (95% CI, 1.3-5.8); P ≤ 0.01), but not with the presence of any PAS disorder (OR, 1.6 (95% CI, 0.7-3.5); P = 0.2). Compared with the group of patients without ultrasound signs of PAS disorder, the presence of at least one typical sonographic sign of PAS disorder in combination with ICL had a DOR of 217.2 (95% CI, 27.7-1703.4; P < 0.001) for placenta percreta and of 687.4 (95% CI, 121.4-3893.0; P < 0.001) for Cesarean hysterectomy.

CONCLUSION

ICL may represent a marker of deep villus invasion in women with suspected PAS disorder on antenatal sonography and anticipate the occurrence of severe maternal morbidity. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Influence of prenatal diagnosis of abnormally invasive placenta on maternal outcome: systematic review and meta-analysis

OBJECTIVE

To ascertain the impact of prenatal diagnosis on surgical outcome of women affected by abnormally invasive placenta (AIP).

METHODS

MEDLINE, EMBASE, CINAHL and Cochrane databases were searched. Observed outcomes included: gestational age at birth (weeks), amount of blood loss (L), units of red blood cells (RBC), platelets (PLT) and fresh frozen plasma (FFP) transfused, length of stay in hospital and the intensive care unit (ICU) (days), urinary tract injury and infection. Only studies reporting the occurrence of any of the explored outcomes in women with a prenatal compared with an intrapartum diagnosis of AIP were considered eligible for inclusion. Random-effect head-to-head meta-analyses were used to analyze the data.

RESULTS

Thirteen studies were included. Women with a prenatal diagnosis of AIP had less blood loss during surgery (mean difference (MD), -0.87; 95% CI, -1.5 to -0.23), had fewer units of RBC (MD, -1.45; 95% CI, -2.9 to -0.04) and FFP (MD, -1.73; 95% CI, -3.3 to -0.2) transfused, and delivered earlier (MD, 1.33 weeks; 95% CI, -2.23 to -0.43) compared with those with an intrapartum diagnosis. The risk of admission to an ICU and length of in-hospital and in-ICU stay were not different between the groups. Prenatal diagnosis of AIP was associated with a higher risk of urinary-tract injury (odds ratio, 2.5; 95% CI, 1.3-4.6), mainly due to the higher prevalence of placenta percreta in the group with AIP diagnosed prenatally.

CONCLUSION

Prenatal diagnosis of AIP is associated with reduced hemorrhagic morbidity compared with cases in which such anomalies are detected at delivery. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta-analysis

OBJECTIVE

To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP).

METHODS

An electronic search of MEDLINE, EMBASE and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for 'Cesarean scar pregnancy' and 'outcome'. Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included: severe first-trimester vaginal bleeding; clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment; uncomplicated miscarriage; complicated miscarriage requiring intervention; first- or second-trimester uterine rupture or hysterectomy; third-trimester bleeding, uterine rupture or hysterectomy; maternal death; incidence of abnormally invasive placenta (AIP); prevalence of placenta percreta; ultrasound signs suggestive of AIP; and live birth. Meta-analyses of proportions using a random-effects model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis.

RESULTS

A total of 17 studies (69 cases of CSP managed expectantly, 52 with and 17 without embryonic/fetal heart beat) were included. In women with CSP and embryonic/fetal heart activity, 13.0% (95% CI, 3.8-26.7%) experienced an uncomplicated miscarriage, while 20.0% (95% CI, 7.1-37.4%) required medical intervention. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI, 2.9-20.4%) of cases, while hysterectomy was required in 15.2% (95% CI, 3.6-32.8%) of all cases. Forty (76.9% (95% CI, 65.4-86.5%)) women progressed to the third trimester of pregnancy, of whom 39.2% (95% CI, 15.4-66.2%) experienced severe bleeding. Finally, 74.8% (95% CI, 52.0-92.1%) had a surgical or pathological diagnosis of AIP at delivery and around two-thirds (69.7% (95% CI, 42.8-90.1%)) of them had placenta percreta. In women with CSP but no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in 69.1% (95% CI, 47.4-87.1%) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 30.9% (95% CI, 12.9-52.6%). Uterine rupture during the first trimester of pregnancy occurred in 13.4% (95% CI, 2.7-30.3%) of cases, but hysterectomy was not required in any case.

CONCLUSIONS

CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidity including severe hemorrhage, early uterine rupture, hysterectomy and severe AIP. Despite this, a significant proportion of pregnancies complicated by CSP may progress to, or close to, term, thus questioning whether termination of pregnancy should be the only therapeutic option offered to these women. Expectant management of CSP with no cardiac activity may be a reasonable option in view of the low likelihood of maternal complications requiring intervention, although close surveillance is advisable to avoid adverse maternal outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

First-trimester detection of abnormally invasive placenta in high-risk women: systematic review and meta-analysis

OBJECTIVES

The primary aim of this systematic review was to ascertain whether ultrasound signs suggestive of abnormally invasive placenta (AIP) are present in the first trimester of pregnancy. Secondary aims were to ascertain the strength of association and the predictive accuracy of such signs in detecting AIP in the first trimester.

METHODS

An electronic search of MEDLINE, EMBASE, CINAHL and Cochrane databases (2000-2016) was performed. Only studies reporting on first-trimester diagnosis of AIP that was subsequently confirmed in the third trimester either during operative delivery or by pathological examination were included. Meta-analysis of proportions, random-effects meta-analysis and hierarchical summary receiver-operating characteristics curve analysis were used to analyze the data.

RESULTS

Seven studies, involving 551 pregnancies at high risk of AIP, were included. At least one ultrasound sign suggestive of AIP was detected in 91.4% (95% CI, 85.8-95.7%) of cases with confirmed AIP. The most common ultrasound feature in the first trimester of pregnancy was low implantation of the gestational sac close to a previous uterine scar, which was observed in 82.4% (95% CI, 46.6-99.8%) of cases. Anechoic spaces within the placental mass (lacunae) were observed in 46.0% (95% CI, 10.9-83.7%) and a reduced myometrial thickness in 66.8% (95% CI, 45.2-85.2%) of cases affected by AIP. Pregnancies with a low implantation of the gestational sac had a significantly higher risk of AIP (odds ratio, 19.6 (95% CI, 6.7-57.3)), with a sensitivity and specificity of 44.4% (95% CI, 21.5-69.2%) and 93.4% (95% CI, 90.5-95.7%), respectively.

CONCLUSIONS

Ultrasound signs of AIP can be present during the first trimester of pregnancy, even before 11 weeks' gestation. Low anterior implantation of the placenta/gestational sac close to or within the scar was the most commonly seen early ultrasound sign suggestive of AIP, although its individual predictive accuracy was not high. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign

OBJECTIVE

Ultrasound assessment of the relationship between the ectopic gestational sac and the endometrial line (cross-over sign; COS) in Cesarean scar pregnancy (CSP) has been shown to be useful in predicting the evolution of CSP towards different types of abnormally invasive placenta (AIP). The aim of this study was to ascertain whether the COS can be used to predict surgical outcome in women with AIP.

METHODS

A retrospective analysis was performed of early first-trimester (6-8 weeks' gestation) ultrasound images of women with AIP managed in the third trimester of pregnancy. We hypothesized that assessment of COS may identify cases of AIP at higher risk of intra- or postsurgical morbidity. Outcomes explored were estimated blood loss during surgery, need for and amount of packed red blood cells and fresh frozen plasma units required either during or after surgery, operative time, intrasurgical complications, gestational age at birth, delivery < 34 weeks of gestation, length of hospital stay and admission to intensive care unit. Differences in the explored outcomes were assessed among women with different types of COS variant (COS-1, COS-2+ or COS-2-) as observed on first-trimester ultrasound examination.

RESULTS

Sixty-eight pregnancies were included in the study. Mean estimated blood loss was higher in AIP pregnancies with COS-1 than in those with COS-2+ (P = 0.039) or COS-2- (P = 0.01). Mean number of packed red blood cell units required during or after the operation was higher in women with COS-1 compared with those with COS-2+ (P = 0.001) and COS-2- (P = 0.029), while there was no difference between pregnancies with COS-2+ and those with COS-2- (P = 0.797). Mean operative time was longer in AIP pregnancies with COS-1 than in those with COS-2+ (P = 0.039) or COS-2- (P = 0.017). Finally, pregnancies with COS-1 were delivered earlier than those with COS-2+ (P = 0.0001) or COS-2- (P = 0.0001).

CONCLUSION

First-trimester ultrasound assessment of the relationship between the ectopic gestational sac and the endometrial line (COS) may identify women with AIP who are at higher risk of intra- or postsurgical morbidity. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Laparoscopic cholecystectomy in the treatment of acute cholecystitis: comparison of outcomes and costs between early and delayed cholecystectomy

BACKGROUND

Several trials showed that early laparoscopic cholecystectomy is superior to delayed laparoscopic cholecystectomy for the treatment of acute cholecystitis. However actual practice does not conform to current evidence. The aim of this study is to compare outcomes and total hospital costs between early and delayed laparoscopic cholecystectomy for acute cholecystitis.

PATIENTS AND METHODS

A retrospective analysis of patients with acute cholecystitis that underwent a laparoscopic cholecystectomy at our institutions was performed. Patients were divided into 2 groups on the basis of the treatment received and statistical analysis was performed.

RESULTS

The study included 91 patients, 52 female and 39 male, with a mean age of 55. Early surgery was performed in 32 cases and delayed surgery in 59 cases. The two groups were comparable for demographics data and severity of disease on admission. There was a no significant difference (p = 0.174) in the mean operative time between early (54.8 min) and delayed group (47.8 min). Conversion rate was higher in the early group (34.3% vs. 20.3%), but difference was not statistically significant (p = 0.223). The overall complications rate was comparable (18.7% early vs. 16.9% delayed, p = 0.941). Length of postoperative stay (4.3 vs. 3.8 days) was similar (p = 0.437), but total hospital stay was significantly 4 days shorter in the early group (p < 0.0001). The mean total cost was higher for the delayed group (4171 vs. 6041), with a significant difference of 1870 Euro (p < 0.0001).

CONCLUSIONS

Early laparoscopic cholecystectomy has an outcome comparable to the delayed procedure, with a shorter total hospital stay and lower total costs, and it should be considered as the preferred approach in treatment of acute cholecystitis.

Preoperative risk factors for conversion from laparoscopic to open cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy has become the standard treatment for symptomatic gallstones. However, a conversion to open surgery is sometimes still required to complete the procedure safely. The aim of this study is to identify the predictive factors of conversion from laparoscopic to open cholecystectomy in both elective and emergency cases.

PATIENTS AND METHODS

A retrospective review of all patients underwent laparoscopic cholecystectomy for symptomatic gallstones from January 2011 to October 2013 was performed. Data considered for analysis were: demographic data, comorbidities, preoperative laboratory values, preoperative ERCP, indication for surgery, and the timing of the intervention in acute cholecystitis. Conversion to open cholecystectomy was chosen as the dependent variable for both, univariate and multivariate analysis.

RESULTS

414 patients underwent laparoscopic cholecystectomy. 245 were female (59.1%) and 169 (40.8%) male, with a mean age of 51.7±16.4 years. The indication for surgery was acute cholecystitis in 91 cases (21.9%). Lithiasis of the bile duct was found in 40 patients (9.6%), and it was identified preoperatively in 37 patients, all treated with a preoperative ERCP. Conversion to open occurred in 33 cases (7.9%). Univariate analysis revealed as risk factor for conversion: increased age, acute cholecystitis, comorbidities, elevated white blood cell count, increased level of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, gamma glutamyl transpeptidase, C-reactive protein, and fibrinogen. Multivariate logistic regression analysis showed that acute cholecystitis (OR 5.63) and age > 65 years (OR 3.025) were independent predictive factors for conversion.

CONCLUSIONS

These patients should be properly informed of their increased risk of conversion and should be operated by surgeons skilled in laparoscopic procedures to reduce this risk.

Comparison of Systemic Flurithromycin Therapy and Clinical Procedures in the Treatment of Periodontal Diseases

The purpose of the present investigation was to evaluate, in 20 periodontal patients, the microbial and clinical effects of flurithromycin therapy plus scaling and root planning (SRP) in comparison with SRP alone. Clinical assessments of plaque, bleeding on probing and pocket depth were made prior to SRP alone and SRP plus flurithromycin therapy (375 mg twice daily for 5 days) and after both treatments. Subgingival plaque samples (n. 180) were taken prior to and after both treatments and analyzed by conventional bacteriological procedures. Differences in pocket depth and prevalence of bacterial species were analyzed pre- and post-therapies using statistical analyses. A significant decrease (p<0.001) was seen for pocket depth post SRP alone and post SRP plus flurithromycin. After two treatments, Actinobacillus actinomycetemcomitans, Bacteroides forsythus and Prevotella melaninogenica were eradicated from all tested sites. If we compare the prevalence of the species isolated after SRP alone and after SRP plus flurithromycin statistically significant differences were detected for P. gingivalis and for Fusobacterium nucleatum (p<0.05 and p<0.01, respectively). Flurithromycin can be considered a useful adjunct to mechanical periodontal treatment since it is more efficient in eliminating periodontal pathogens.

Morbidly adherent placenta: evaluation of ultrasound diagnostic criteria and differentiation of placenta accreta from percreta

OBJECTIVES

To evaluate the diagnostic accuracy of two-dimensional (2D) gray-scale and color Doppler and three-dimensional (3D) power Doppler sonographic criteria for morbidly adherent placenta (MAP), and to identify criteria to help distinguish placenta accreta from placenta percreta.

METHODS

We enrolled 187 patients with placenta previa and history of uterine surgery and performed transabdominal and transvaginal ultrasound examination for early detection of MAP. With 2D gray-scale transabdominal and transvaginal ultrasonography, we investigated loss/irregularity of the echolucent area between the uterus and the placenta ('clear space'), thinning or interruption of the hyperechoic interface between the uterine serosa and the bladder wall and the presence of turbulent placental lacunae with high-velocity flow (>15 cm/s). Using transabdominal 3D power Doppler, we evaluated the hypervascularity of the uterine serosa-bladder wall interface and irregular intraplacental vascularization. Ultrasound findings were reviewed against the final diagnosis made during Cesarean section (CS).

RESULTS

MAP was detected on CS in 41 patients. All of them had an anterior placenta previa (34 major and seven minor) and had undergone at least one previous CS. The evaluated sonographic criteria showed good diagnostic performance; in MAP patients at least two out of five criteria were detected, with at most one of the criteria present in patients without MAP. Loss/irregularity of clear space used as a single criterion was responsible for the most false positives, demonstrating a low positive predictive value. Irregular intraplacental vascularization with tortuous confluent vessels affecting the entire width of the placenta, and hypervascularity of the entire uterine serosa-bladder wall interface, were only detected, on 3D power Doppler, in cases of placenta percreta.

CONCLUSIONS

The reviewed ultrasound criteria may be useful for the prenatal diagnosis of MAP and to differentiate between placenta accreta and placenta percreta; 3D power Doppler techniques were an important aid in the diagnosis.

Increased mucosal nitric oxide production in ulcerative colitis is mediated in part by the enteroglial-derived S100B protein

In the central nervous system glial-derived S100B protein has been associated with inflammation via nitric oxide (NO) production. As the role of enteroglial cells in inflammatory bowel disease has been poorly investigated in humans, we evaluated the association of S100B and NO production in ulcerative colitis (UC). S100B mRNA and protein expression, inducible NO synthase (iNOS) expression, and NO production were evaluated in rectal biopsies from 30 controls and 35 UC patients. To verify the correlation between S100B and NO production, biopsies were exposed to S100B, in the presence or absence of specific receptor for advanced glycation end-products (RAGE) blocking antibody, to measure iNOS expression and nitrite production. S100B and iNOS expression were evaluated after incubation of biopsies with lipopolysaccharides (LPS) + interferon-gamma (IFN-gamma) in the presence of anti-RAGE or anti-S100B antibodies or budesonide. S100B mRNA and protein expression, iNOS expression and NO production were significantly higher in the rectal mucosa of patients compared to that of controls. Exogenous S100B induced a significant increase in both iNOS expression and NO production in controls and UC patients; this increase was inhibited by specific anti-RAGE blocking antibody. Incubation with LPS + IFN-gamma induced a significant increase in S100B mRNA and protein expression, together with increased iNOS expression and NO production. LPS + IFN-gamma-induced S100B up-regulation was not affected by budesonide, while iNOS expression and NO production were significantly inhibited by both specific anti-RAGE and anti-S100B blocking antibodies. Enteroglial-derived S100B up-regulation in UC participates in NO production, involving RAGE in a steroid insensitive pathway.

Myenteric neuronal loss in rats with experimental colitis: role of tissue transglutaminase-induced apoptosis

BACKGROUND AND AIMS

Transglutaminases are tissue enzymes involved in different neuronal processes including maintenance and signalling. However, their up-regulation elicited by a variety of noxae contributes to neurodegeneration. This study tested the hypothesis that experimental inflammation evoked transglutaminase up-regulation in myenteric neurons and that this event had an impact on neuronal survival.

METHODS

Rats with or without trinitro-benzene-sulphonic acid-induced colitis were used. One week after colitis induction, longitudinal muscle-myenteric plexus preparations were obtained from left colon to assess tissue-transglutaminase activity, protein and mRNA expression. Double labelling immunofluorescence using antibodies to neuron-specific enolase and transglutaminase was performed to identify myenteric neurons expressing transglutaminase. Additional sets of experiments evaluated the involvement of transglutaminase in the apoptotic process of cultured myenteric neurons.

RESULTS

Compared to controls, rats with colitis showed several tranglutaminase/neuron-specific enolase positive myenteric neurons. Western blot analysis and RT-PCR confirmed that in rats with colitis, the increased neuronal transglutaminase-immunoreactivity was associated with an increased enzyme expression. Similarly, transglutaminase activity was significantly higher than in controls (1100+/-280 m U/g vs. 725+/-119 m U/g, p<0.05). In cultured myenteric neurons incubation with the specific transglutaminase inducer, retinoic acid, significantly increased neuronal apoptosis, whereas the presence of cystamine significantly reduced the number of apoptotic neurons.

CONCLUSIONS

Experimental colitis evoked transglutaminase up-regulation and increased activity in myenteric neurons. This mechanism enhances neuronal susceptibility to apoptosis and could contribute to neuropathic changes during gut inflammation.

[Fetal pseudohypoaldosteronism: rare cause of hydramnios]

PHA is a rare cause of hydramnios, characterized by increased amniotic fluid levels of aldosterone and sodium. Two distinct genetic entities (PHA type I and PHA type II) are included. Both are stemmed by a target organ defect with diminished renal tubular responsiveness to aldosterone. The AA present a case in which pregnancy resulted in a preterm infant with severe hydramnios, metabolic acidosis, hyponatriemia, hyperkaliemia. Salt and fluid replacement significantly improved clinical and metabolic condition. However a growth deficiency (-2 SDS) persists at follow-up.

[Fetal pseudohypoaldosteronism: a rare cause of hydramnios]

PHA is a rare cause of hydramnios, characterized by increased amniotic fluid levels of aldosterone and sodium. Two distinct genetic entities (PHA type I and PHA type II) are included. Both are stemmed by a target organ defect with diminished renal tubular responsiveness to aldosterone. The AA present a case in which pregnancy resulted in a preterm infant with severe hydramnios, metabolic acidosis, hyponatriemia, hyperkaliemia. Salt and fluid replacement significantly improved clinical and metabolic condition. However a growth deficiency (-2 SDS) persists at follow-up.

Ventilation-perfusion lung scan for the detection of pulmonary involvement in Takayasu's arteritis

The aim of study was to analyse ventilation and perfusion (V/Q) lung scan findings in a series of Italian patients with Takayasu's arteritis. Eighteen consecutive patients underwent V/Q lung planar scintigraphy and single-photon emission tomography (SPET). Before perfusion scan acquisition was started, a first-pass study with (99m)Tc-macroaggregates of albumin was performed to assess the right ventricular ejection fraction (RVEF). All patients had normal chest X-rays and were symptom free at the time of the investigation. They also underwent echocardiography to evaluate pulmonary artery pressure and in 13 patients respiratory function tests were performed. In four patients, perfusion lung scan was repeated after 1 year. In 10/18 patients (55.5%), 43 unmatched lobar, segmental or subsegmental perfusion defects were found on planar images; ventilation scintigraphy was normal in all cases. On SPET images, 55 defects were found; no defects were found with SPET in the remaining patients who had normal planar images. All patients had normal RVEF and 5/13 patients had mild restrictive-obstructive lung disease. The pulmonary artery pressure was increased in two patients with perfusion defects. In the four patients who had repeat scintigraphy, all defects remained unchanged. The prevalence of lung perfusion abnormalities observed in Italian patients with Takayasu's arteritis is within the range of values reported in other countries, and V/Q planar scintigraphy is sufficient for the screening of patients.

Porphyromonas gingivalis prevalence related to other micro-organisms in adult refractory periodontitis

Forty-six adult periodontal patients, selected on the basis of clinical examination, and 46 adult healthy subjects were examined. The subgingival plaque samples from one inflammatory and one non-inflammatory site of each periodontal patient were studied to determine Porphyromonas gingivalis prevalence related to other periodontal micro-organisms and to periodontal tissue destruction. The results showed Porphyromonas gingivalis as the main pathogenic micro-organism isolated in the inflammatory sites together with Bacteroides forsythus. Peptostreptococcus sp., Actinomyces sp. and Prevotella sp. were found as a normal oral flora in the healthy subjects. Fusobacterium nucleatum, Prevotella intermedia, Campylobacter rectus and Eikenella corrodens were detected both in inflammatory and in non-inflammatory sites of periodontal patients as well as in the healthy subjects.

RhoA activity is required for fibronectin assembly and counteracts beta1B integrin inhibitory effect in FRT epithelial cells

FRT thyroid epithelial cells synthesize fibronectin and organize a network of fibronectin fibrils at the basal surface of the cells. Fibronectin fibril formation is enhanced by the overexpression of the ubiquitous beta1A integrin and is inhibited by the expression of the dominant-negative beta1B subunit. We tested the hypotheses that RhoA activity might mediate the integrin-dependent fibronectin fibrillogenesis and might counteract beta1B integrin inhibitory effect. FRT-beta1A cells were transfected with a vector carrying a dominant negative form of RhoA (RhoAN19) or treated with the C3 transferase exoenzyme. Both treatments inhibited fibronectin assembly and caused loss of actin microfilaments and adhesion plaques. On the other hand, FRT-beta1B cells were transfected with the constitutively activated form of RhoA (RhoAV14) or treated with the E. coli cytotoxic necrotizing factor 1, which directly activates RhoA. Either treatment restored microfilament and adhesion plaque assembly and promoted fibronectin fibril organization. A great increase in fibronectin fibril assembly was also obtained by treatment of FRT-beta1B cells with TGF-beta. Our data indicate that RhoA is required to promote fibronectin matrix assembly in FRT cells and that the activation of the signal transduction pathway downstream of RhoA can overcome the inhibitory effect of beta1B integrin.

Non-invasive assessment of pulmonary artery involvement in Takayasu's arteritis

OBJECTIVE

To evaluate pulmonary involvement in Italian patients with Takayasu's arteritis (TA).

METHODS

A prospective analysis of 15 Italian patients with TA was carried out, including evaluation by perfusion and ventilation lung scintigraphy (planar and tomographic), standard chest X-ray, spirography and color-doppler echocardiography. All the patients were free of respiratory symptoms when examined.

RESULTS

In all patients standard chest X-rays and ventilation scintigraphies were normal. 9/15 patients showed unmatched segmental perfusion defects (41 by planar evaluation vs. 48 by SPET). The number of defects was greater in the right lung than in the left (26 vs 18), with a higher frequency of moderate or large defects. Thirteen patients underwent spirography, which proved to be abnormal in 5 cases. Two of these patients were also positive on scintigraphy. No patient showed alterations attributable to TA on color-doppler echocardiography, except for 3 patients with mild to moderate aortic valve regurgitation.

CONCLUSIONS

Our results show that vascular pulmonary involvement is frequent in TA (60% of cases) even in the absence of clinical signs. The planar image, simpler than the SPET to acquire, was sufficient to make an accurate diagnosis. Italian patients seem to show a pattern of extrapulmonary and pulmonary vascular involvement very similar to that reported in Japanese subjects, and different from that observed in other ethnic groups.

Isolation of Porphyromonas gingivalis and detection of immunoglobulin A specific to fimbrial antigen in gingival crevicular fluid

The present study evaluated the prevalence of Porphyromonas gingivalis and the correlation between the bacterial culture method and the detection of immunoglobulin A (IgA) specific to the P. gingivalis fimbrial antigen in gingival crevicular fluid (GCF). P. gingivalis was isolated from 78.3% of subgingival plaque samples obtained from active sites and 34.7% of those from inactive sites of periodontal patients. P. gingivalis was isolated from only 4.7% of healthy subjects (control group). Immunoglobulins specific to the P. gingivalis fimbrial antigen were detected by enzyme-linked immunosorbent assay (ELISA). The overall agreement between the results of the P. gingivalis culture method and the results of specific IgA detection in periodontal patients was 71.7% for active sites and 58.7% for inactive sites. IgA specific to P. gingivalis was absent in GCF from all of the sites of healthy subjects. The results suggest that P. gingivalis is associated with the local production of specific IgA. The detection of IgA antibodies specific to P. gingivalis in GCF by ELISA may be used as a predictive parameter to reveal the early phase of the activation of recurrent periodontal infections.

Transfection of TTF-1 gene induces thyroglobulin gene expression in undifferentiated FRT cells

The thyroglobulin gene, the substrate for thyroid hormone biosynthesis, is not expressed in the FRT cell line, which, even though it manifests the polarised epithelial phenotype, does not express any of the thyroid functional properties. Two transcription factors, TTF-1 and Pax-8, have been implicated in thyroid specific expression of the thyroglobulin gene. FRT cells contain Pax-8 but they lack TTF-1. In this paper, we show that transfection of TTF-1 expression vectors in FRT cells results in activation of thyroglobulin gene expression. If the expression vector encoded for TTF-1-ER, a fusion gene coding for the entire TTF-1 protein fused to the hormone-binding domain of the steroid receptor, under the control of the RSV promoter, thyroglobulin gene expression was controlled by estrogen. These data provide a direct demonstration that TTF-1 activates the chromosomal thyroglobulin promoter. Since transfection of TTF-1 expression vectors in non-thyroid cell types did not result in thyroglobulin gene expression, it is suggested that Pax-8, in addition, perhaps, to a specific cellular environment, might be required for thyroid specific expression of the thyroglobulin gene.

Antimicrobial interference of a subinhibitory concentration of azithromycin on fimbrial production of Porphyromonas gingivalis

The first pathogenic mechanism of Porphyromonas gingivalis, which is mainly responsible for adult periodontal diseases, is the attachment of fimbriae appendages to oral epithelial cells. The ability of a subinhibitory concentration of azithromycin to inhibit the expression of fimbriae in various strains of P. gingivalis isolated was investigated. A one-eighth subinhibitory concentration of azithromycin was evaluated in vitro. The antibiotic was active in 75% of P. gingivalis strains isolated, judged by both electrophoresis and transmission electron microscopy. The results indicate that the subinhibitory concentration of azithromycin is capable of blocking the pathogenic mechanism of P. gingivalis in vitro, and, therefore, can be used in vivo as a treatment for recurrent periodontitis.

Prevention and morbidity of malaria in non-immune subjects; a case-control study among Italian troops in Somalia and Mozambique, 1992-1994

The impact of malaria on Italian troops taking part in 1992-1994 in the United Nations Organization humanitarian missions in Somalia and Mozambique is discussed. In Somalia, 18 cases of Plasmodium falciparum malaria occurred among 11,600 soldiers; the overall attack rate was 0.4 cases/1000/month of exposure and the risk of malaria was effectively reduced by chemoprophylaxis with chloroquine plus proguanil (C+P) (odds ratio [OR] = 0.05, 95% confidence limits [95% CL] 0.02-0.16). In Mozambique, 119 cases of P.falciparum malaria occurred among 4800 soldiers; most cases (100) occurred in the first months of deployment (late March-June 1993), with an attack rate of 17 cases/1000/month, when C+P was the recommended chemoprophylactic regimen; the remaining 19 cases occurred subsequently, with an attack rate of 1.8 cases/1000/month, after C+P was replaced by mefloquine in July 1993. Protection achieved by C+P was unsatisfactory (OR = 0.37, 95% CL 0.21-0.67), while chemoprophylaxis with mefloquine effectively reduced the risk of malaria in Mozambique (OR = 0.03; 95% CL 0.01-0.10). A significant number of malaria infections was also detected among soldiers following their return home from Somalia (147 cases) and Mozambique (40 cases); these were due mainly to P. vivax. Fifteen of 113 P. vivax primary infections imported from Somalia (13.3%) relapsed 2-13 months after the primary attack. Because of the small proportion of relapsing P. vivax tropical strains, primaquine may be limited to radical treatment of relapses or, more extensively, of all P. vivax infections, but it should not be necessarily given to all asymptomatic subjects returning from tropical endemic areas, as is generally suggested for particular groups at risk.

Collagen interaction with apically expressed beta 1 integrins: loss of transepithelial resistance and reorganization of cultured thyroid cell monolayer

We have cultured FRT rat thyroid cells to confluency on filters in bicameral systems and allowed a type I collagen solution to gel on their apical compartment. A dramatic drop in transepithelial resistance occurred within 2 h after collagen addition. This drop in transepithelial resistance was dependent upon collagen concentration. Cells interacting with the collagen lost their apical microvilli, formed pseudopods and displayed rearrangements in the distribution of actin and uvomorulin. After 24 h the cells had reorganized in two layers, one facing the other, with opposite orientations. We found that in approximately 15 to 20% of the cells within a confluent monolayer alpha 1 and beta 1 integrin subunits were localized in a subdomain of the apical plasma membrane, other than on the basolateral surface, as they normally are. By double immunofluorescence, after addition of diluted collagen solutions, we were able to detect collagen fibers that were bound to these integrin-containing apical subdomains. The addition of anti-beta 1 antibodies to the apical domain significantly delayed the drop in transepithelial resistance induced by the collagen gel. These data suggest that members of the beta 1 integrin family that are expressed on the apical domain may act as receptors for collagen fibers and may play a role in promoting changes in cell orientation.

The Italian Army Medical Corps in the United Nations "peace-keeping" operations: Somalia and Mozambique, December 1992-December 1994

The Italian Army took part in the United Nations peace keeping operations in Somalia from December 1992 to March 1994 and in Mozambique from April 1993 to December 1994. These two missions involving a total of 16,358 men were very different technically, logistically, and epidemiologically. In Somalia the main pathology observed was traveler's diarrhea which affected 55% of the personnel. In Mozambique the main problem was malaria. A combination of chloroquine and proguanil was poorly effective but replacement with mefloquine gave good results. These two missions which were the first undertaken by the Italian Army outside the Mediterranean basin since the Second World War allowed testing of the readiness of materials, equipment, and personnel. Other missions in Lebanon, Turkey, Kurdistan, and Albania greatly benefited from the information obtained in these two initial operations.

[Acute anterior myocardial infarction in a patient with left atrial myxoma during pregnancy]

It is a case report of a patient who had an acute anterior myocardial infarction during the 22th week of pregnancy, probably due to coronary embolization from a large left atrial myxoma. The patient had a previous operation for a right adrenal adenoma causing a Cushing Syndrome. It is hypotized an association between adrenal adenoma and atrial myxoma, like "Carney Syndrome".

Expression of the RET oncogene induces differentiation of SK-N-BE neuroblastoma cells

Expression of the RET proto-oncogene, a cell surface receptor for an as yet unknown ligand, is associated with tumors, tissues, and cell lines of neural crest origin. Accumulating evidence suggests that RET activity is involved in the process of neuronal differentiation. Moreover, induction of phenotypic differentiation of neuroblastoma cell lines is associated with the rapid accumulation of RET transcripts. To verify the role of RET in neuronal differentiation, we introduced into the human neuroblastoma cell line SK-N-BE four versions of the RET oncogene, activated by different mechanisms: RET/PTC1 and RET/PTC3, which are activated by rearrangement with heterologous genes; and two activated RET mutants, which carry the single amino acid substitution found associated to the inheritance of the multiple endocrine neoplasia type 2A (retMEN2A allele) and type2B (retMEN2B allele), respectively. We demonstrate that, after transfection with the RET oncogenes, SK-N-BE cells display a reduced growth rate and acquire a neurite-bearing phenotype accompanied by enhanced expression of the axonal growth-associated protein, GAP-43, and the high molecular weight neurofilament, NF200. These results indicate that, when activated, RET is able to cause growth inhibition and to promote neuronal differentiation of neuroblastoma cells.

[Clarithromycin in the treatment of oral infections]

The authors show the results of a clinical study to test the efficacy and the tolerance of clarithromycin when used in the treatment of odontological infections. Forty-one subjects were selected for the study. All the subjects were affected by odontological infections and needed antibiotic therapy. The results obtained are satisfactory and demonstrate the effectiveness of the use of clarithromycin in the treatment of odontological infections.

Transthoracic high-frequency echocardiographic detection of atherosclerotic lesions in the descending portion of the left coronary artery

To assess the ability of transthoracic high-frequency two-dimensional echocardiography to detect atherosclerotic lesions in the descending portion of the left coronary artery, 30 consecutive patients with suspected coronary artery disease underwent two-dimensional echocardiographic examination 24 to 96 hours before coronary angiography. The descending portion of the left coronary artery was arbitrarily divided into a mid segment (the portion of the coronary vessel embedded in the anterior interventricular sulcus) and an apical segment (the portion turning around the cardiac apex into the posterior interventricular sulcus). The mid segment was imaged in 24 and the apical segment in 25 of the 30 patients for a total of 49 out of 60 segments (82%). Comparison of the echocardiographically visualized segments with the corresponding angiographic segments indicated that a correct echocardiographic diagnosis of significant stenosis was made in 11 out of 12 segments. There were no false positive results. Thus the sensitivity and specificity of high-frequency transthoracic echocardiography in the detection of significant stenosis in the imaged segments were 92% and 100%, respectively. Compared with angiography, additional information concerning the status of the arterial wall, the presence of calcific plaques, and the cross-sectional extent of the obstructive lesions was obtained by echocardiography in eight patients.

[Surgical revascularization of the myocardium for atresia of the left main coronary artery and atherosclerotic coronary disease]

The authors report a rare case of atresia of the left main coronary artery in an adult patient, symptomatic for effort angina. At coronarography, the left main coronary artery was not found; instead, the arteries of the left coronary tree were filled via a single collateral vessel arising from the ostium of the right coronary artery and ending in the trunk of the left anterior descending artery. All left arteries had very narrow calibres, almost hypoplastic, while the right coronary artery had a normal calibre. All the principal arteries had important stenoses. The patient underwent complete cardiac revascularization, and, sixteen months later, is free from angina. Rest and stress myocardial scintigraphy, control coronary angiography and Doppler analysis of internal mammary artery flow demonstrated normal myocardial perfusion, adequate blood flow through the grafts and good runoff in the native vessels. Hence, the authors conclude that such patients should be referred for coronary artery revascularization, since surgical results are good and the small calibre of the left coronary arteries is no contraindication.

Polarized secretion of plasminogen activators by epithelial cell monolayers

We have investigated the synthesis and the polarized secretion of plasminogen activators (PAs) in three epithelial cell lines (FRT, derived from rat thyroid; MDCK, from canine kidney, and CaCo-2, from human intestine) grown on filters, in bicameral systems. Confluency and acquisition of functional polarity were assessed by measuring transepithelial resistance and by showing polarized secretion of endogenous proteins. By zymography, before and after immunoprecipitation with specific antibodies, we found that FRT cells synthesized tissue plasminogen activator (tPA) and that tPA activity was mostly confined to the apical cell compartment. MDCK and CaCo-2 cells, instead, synthesized urokinase-type plasminogen activator (uPA). In MDCK cells the uPA activity was found predominantly in the apical cell compartment while in CaCo-2 cells it was mostly basolateral.