Depression and routinization following stroke

OBJECTIVE

Post-stroke depression is a frequent complication of stroke that has detrimental consequences for quality of life and functional outcomes. Daily life routines may increase feelings of security for some individuals confronted with age-related health concerns, but little information is available concerning their role following stroke. The aim of this investigation was to examine the association of depression and other psychological variables at hospitalization for stroke and behavioral routines and mood symptoms three months later using Ecological Momentary Assessment (EMA).

METHODS

Forty-four patients with minor ischemic stroke were consecutively enrolled in the study. Stroke severity, handicap, depression and anxiety symptoms were assessed at baseline. EMA data acquired three months later were coded for the repetition of specific activities or behaviors occurring within the same time period across days.

RESULTS

Higher baseline depression and anxiety symptom severity were significantly associated with increased behavioral routines three months after stroke. The occurrence of routines was associated with a higher level of depressive symptomatology over subsequent hours of the day.

CONCLUSION

The findings demonstrate a general correlation between baseline psychological vulnerability and routines three months later, but within-day analyses suggest that routines may increase the risk of negative affect in this vulnerable population.

Influence of inflammatory status in the acute phase of stroke on post-stroke depression

BACKGROUND

Thirty percent of stroke patients will suffer from post-stroke depression (PSD). Recent data suggest that inflammation accounts for a substantial amount of depression. Our primary objective was to assess the association between standard inflammation biomarkers in the acute phase of stroke and PSD at three months. The secondary objective was to elaborate a predictive model of PSD from clinical, biological and radiological data.

METHODS

We performed a retrospective analysis of a single-centre cohort of stroke patients with a three-month follow-up. Serum levels of C-reactive protein (CRP), fibrinogen, leukocyte count and neutrophil to lymphocyte ratio (NLR) were tested at admission and at peak. Mood was assessed at three months using the depression sub-scale of the Hospital Anxiety and Depression Scale (HADS). Association between inflammation biomarkers and HADS was evaluated with multi-linear regression adjusted on clinical and radiological parameters. Logistic predictive models of PSD at three months, with and without inflammation biomarkers, were compared.

RESULTS

Three hundred and forty-eight patients were included, of whom 20.06% developed PSD. Baseline and peak values of all inflammatory markers were associated with the severity of PSD at three months. Area under the curve for the receiver operating characteristic curve of PSD prediction was 0.746 (CI 95% 0.592-0.803) with selected inflammation biomarkers and 0.744 (CI 95% 0.587-0.799) without.

CONCLUSION

Most inflammation biomarkers are weakly associated with PSD, adding negligible value to predictive models. While they suggest the implication of inflammation in PSD pathogenesis, they are useless for the prediction of PSD, underscoring the need for more specific biomarkers.

Acute Ischemic Stroke or Epileptic Seizure? Yield of CT Perfusion in a "Code Stroke" Situation

BACKGROUND AND PURPOSE

The clinical differentiation between acute ischemic stroke and epileptic seizure may be challenging, and making the correct diagnosis could avoid unnecessary reperfusion therapy. We examined the accuracy of CTP in discriminating epileptic seizures from acute ischemic stroke without identified arterial occlusion.

MATERIALS AND METHODS

We retrospectively identified consecutive patients in our emergency department who underwent CTP in the 4.5 hours following the development of an acute focal neurologic deficit who were discharged with a final diagnosis of acute ischemic stroke or epileptic seizure.

RESULTS

Among 95 patients, the final diagnosis was epileptic seizure in 45 and acute ischemic stroke in 50. CTP findings were abnormal in 73% of the patients with epileptic seizure and 40% of those with acute ischemic stroke. Hyperperfusion was observed more frequently in the seizure group (36% versus 2% for acute ischemic stroke) with high specificity (98%) but low sensitivity (35%) for the diagnosis of epileptic seizure. Hypoperfusion was found in 38% of cases in each group and was not confined to a vascular territory in 24% of patients in the seizure group and 2% in the acute ischemic stroke group. The interobserver agreement was good (κ = 0.60) for hypo-, hyper-, and normoperfusion patterns and moderate (κ = 0.41) for the evaluation of vascular systematization.

CONCLUSIONS

CTP patterns helped to differentiate acute ischemic stroke from epileptic seizure in a "code stroke" situation. Our results indicate that a hyperperfusion pattern, especially if not restricted to a vascular territory, may suggest reconsideration of intravenous thrombolysis therapy.

The impact of intravenous thrombolysis on outcome of patients with acute ischemic stroke after 90 years old

Background

Age increases the risk of mortality and poor prognosis following stroke. The benefit of intravenous thrombolysis in very old patients remains uncertain. The purpose of the study was to evaluate the efficacy and safety of thrombolysis in very old patients considering their perfusion-imaging profile.

Methods

We conducted a retrospective study including patients older than 90 y.o. admitted for an acute ischemic stroke. A computed tomography perfusion-imaging (CTP) was performed in patients who received thrombolysis. Primary outcome was the functional status at 3 months, assessed by the modified Rankin scale (mRS). Secondary outcomes were the rate of hemorrhagic transformations, duration of hospitalization and the rate of death in the first 7 days. Patients receiving thrombolysis were compared with an age-matched group of non-thrombolysed patients.

Results

78 patients were included (31 % male, aged 92 ± 1.7 y.o). 37 patients received thrombolysis and among them, 30 had CTP with a mismatch. The three months mRS was not significantly different in the two groups (mRS 0–2: 5 % and 7 % in the thrombolysed and non-thrombolysed group, respectively). Hemorrhagic transformations were more frequent in the thrombolysed group (54 % versus 12 %, p = 0.002) and symptomatic intracranial hemorrhage tended to be associated with mRS at three months and death in the first 7 days. Duration of hospitalization was longer in the thrombolysed group (10 days ± 12 versus 7 days ± 9, p = 0.046).

Conclusions

Patients who received thrombolysis did not have a better functional prognosis than non-thrombolysed patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0331-1) contains supplementary material, which is available to authorized users.

Lucid dreams, an atypical sleep disturbance in anterior and mediodorsal thalamic strokes

BACKGROUND

Cognitive, affective, and behavioural disturbances are commonly reported following thalamic strokes. Conversely, sleep disorders are rarely reported in this context.

OBSERVATIONS

Herein, we report the cases of two young patients admitted for an ischemic stroke located in the territories of the left pre-mammillary and paramedian arteries. Together with aphasia, memory complaint, impaired attention and executive functions, they reported lucid dreams with catastrophic content or conflicting situations.

CONCLUSION

Lucid dreams are an atypical presentation in thalamic strokes. These cases enlarge the clinical spectrum of sleep-wake disturbances potentially observed after an acute cerebrovascular event.

Caseous calcification of the mitral annulus associated with stroke: report of two cases

OBJECTIVE

Caseous calcification of the mitral annulus (CCAM) is a rare complication of mitral annulus calcification (MAC). Whether CCAM should be considered as a cardiac source of stroke or a simple marker of atherosclerosis remains a matter of debate.

METHOD

Herein, we report two patients with stroke and CCAM.

RESULTS

The first one was associated with extensive aortic arch atheroma, while CCAM was the only potential cause in the second case. Transthoracic echocardiography was normal in both cases and CCAM was diagnosed on transesophageal echocardiography.

CONCLUSION

These observations suggest that CCAM should be added to the list of minor cardioembolic sources of stroke but also requires a perfect control of vascular risk factors.

Atraumatic nonaneurysmal sulcal subarachnoid hemorrhages: a diagnostic workup based on a case series

INTRODUCTION

Atraumatic and nonaneurysmal sulcal subarachnoid hemorrhage (sSAH) is a rare type of cerebrovascular disease with various etiologies previously reported in small case reports. In this study, we propose to analyze clinical presentations, imaging patterns and etiologies in a large case series of such patients in order to propose a diagnostic workup.

METHODS

We retrospectively analyzed clinical and radiological data of consecutive patients with a diagnosis of atraumatic and nonaneurysmal sSAH, admitted to our institution between 2008 and 2011. All patients had both computed tomography (CT) and magnetic resonance imaging (MRI) as a part of their initial evaluation.

RESULTS

30 patients (18 women and 12 men, mean age: 60 years) were identified. The main clinical symptoms at presentation were focal and transient neurological deficit (n = 22) and thunderclap headache (n = 10). Four patients had progressive headache and 4 other had partial or generalized epileptic seizures. MRI abnormalities associated with sSAH were prior hemorrhages, microbleeds, severe leukoencephalopathy and hemosiderosis suggesting cerebral amyloid angiopathy (CAA; n = 9), vasogenic edema in parieto-occipital areas compatible with a posterior reversible encephalopathy syndrome (PRES; n = 3), cortical venous thrombosis (n = 2) and concomitant acute cortical stroke (n = 3). Other underlying causes of sSAH, not diagnosed on MRI, were reversible cerebral vasoconstriction syndrome (RCVS) based on clinical criteria and conventional angiography (n = 4), angiitis diagnosed by skin biopsy (n = 1), vascular malformation diagnosed on CT and digital subtraction angiographies (n = 3), and overanticoagulation (n = 1). Four cases remained unresolved.

CONCLUSION

This study confirmed that sSAH is a rare condition related to a wide spectrum of etiologies. Combination of brain MRI and magnetic resonance angiography and eventually digital subtraction angiography allowed the identification of an underlying etiology for 87% of patients. CAA, RCVS and PRES represented more than 50% of the etiological mechanisms. Among older patients, sSAH was mainly related to CAA while in younger patients, RCVS represented the most frequent etiology.

Final cerebral infarct volume is predictable by MR imaging at 1 week

BACKGROUND AND PURPOSE

Stroke volume, an increasingly used end point in phase II trials, is considered stationary at least 30 days after the ictus. We investigated whether information conveyed by MR imaging measurements of the "final" infarct volume could be assessed as early as the subacute stage (days 3-6), rather than waiting for the chronic stage (days 30-45).

MATERIALS AND METHODS

Ninety-five patients with middle cerebral artery stroke prospectively included in a multicenter study underwent MR imaging during the first 12 hours (MR imaging-1), between days 3 and 6 (MR imaging-2), and between days 30 and 45 (MR imaging-3). We first investigated the relationship between subacute (FLAIR-2) and chronic volumes (FLAIR-3), by using a linear regression model. We then tested the relationship between FLAIR volumes (either FLAIR-2 or FLAIR-3) and functional disability, measured by the mRS at the time of MR imaging-3, by using logistic regression. The performances of the models were assessed by using the AUC in ROC.

RESULTS

A linear association between log FLAIR-2 and log FLAIR-3 volumes was observed. The proportion of FLAIR-3 variation, explained by FLAIR-2, was high (R(2) = 81%), without a covariate that improved this percentage. Both FLAIR-2 and FLAIR-3 were independent predictors of mRS (OR, 0.79 and 0.73; 95% CI, 0.64-0.97 and 0.56-0.96; P = .026 and .023). The performances of the models for the association between either FLAIR volume and mRS did not differ (AUC = 0.897 for FLAIR-2 and 0.888 for FLAIR-3).

CONCLUSIONS

Stroke damage may be assessed by a subacute volume because subacute volume predicts the "true" final volume and provides the same clinical prognosis.

Reliability of the ECASS radiological classification of postthrombolysis brain haemorrhage: a comparison of CT and three MRI sequences

BACKGROUND

Postthrombolysis brain haemorrhagic transformations (HT) are often categorized with the CT-based classification of the European Cooperative Acute Stroke Study (ECASS). However, little is known about the reliability of this classification and its extension to MRI. Our objective was to compare the inter- and intraobserver reliability of this classification on CT and 3 MRI sequences.

METHODS

Forty-three patients with postthrombolysis HT on CT or at least 1 of the 3 MRI sequences: fluid-attenuation inversion recovery (FLAIR), diffusion-weighted imaging (DWI), and T2* gradient recalled echo (T2*GRE) were selected. Twelve control patients without any bleeding were added to avoid a bias based on a pure HT-positive cohort. Each series of images were independently classified with the ECASS method by 6 blinded observers. Inter- and intraobserver reproducibility was categorized from poor to excellent depending on kappa values.

RESULTS

The inter- and intraobserver overall concordance of the classification was good for T2*GRE, DWI and CT (kappa > 0.6) and moderate for FLAIR (kappa < 0.6). The interobserver concordance for parenchymal haematomas was excellent for T2*GRE (kappa > 0.8) and moderate for CT, FLAIR and DWI.

CONCLUSION

The T2*GRE sequence is the most reproducible method to categorize postthrombolysis HT and has an excellent reliability for the severe parenchymal haematoma category, suggesting that this sequence should be used to assess HT in thrombolytic therapy trials.

Feasibility and validity of computerized ambulatory monitoring in stroke patients

BACKGROUND

Computerized ambulatory monitoring provides real-time assessments of clinical outcomes in natural contexts, and it has been increasingly applied in recent years to investigate symptom expression in a wide range of disorders. The purpose of this study was to examine the feasibility and validity of this data collection strategy with adult stroke patients.

METHODS

Forty-eight individuals (75% of the contacted sample) agreed to participate in the current study and were instructed to complete electronic interviews using a personal digital assistant 5 times per day over a 1-week period.

RESULTS

More than 80% of programmed assessments were completed by the sample, and no evidence was found for fatigue effects. Expected patterns of associations were observed among daily life variables, and data collected through ambulatory monitoring were significantly correlated with standard clinic-based measures of similar constructs.

CONCLUSION

Support was found for the feasibility and validity of computerized ambulatory monitoring with stroke patients. The application of these novel methods with stroke patients should provide complementary information that is inaccessible to standard hospital-based assessments and permit increased understanding of the significance of clinical results and test scores for daily life experience.

Instruments de mesure et échelles d’évaluation utilisés dans la démence fronto-temporale

In frontotemporal dementia (FTD), evaluation scales and measurement instruments are less codified than in Alzheimer's disease. Some nonspecific scales are available, two of which are very useful for early diagnose of the disease: Lebert and Pasquier's Frontotemporal Behavioral Scale (FBS) to assess behavioral disturbances and Dubois's Frontal Assessment Battery (FAB) to assess executive ability. However, these scales do not contain enough items to follow up FTD. The main scale used to follow up the disease is the Neuropsychiatric Inventory (NPI). The Frontal Behavioural Inventory (Kertesz) seems to be interesting, but has not yet been validated in France. The Mattis Dementia Rating Scale, not specific for FTD, is used to assess the cognitive rate. The activities of daily living scales and caregiver burden are not well known in FTD.

[Palpable mantel cell lymphoma in the breast]

BACKGROUND

Extranodal involvement is not unusual in mantle cell lymphoma (MCL) which accounts for 6% of non-Hodgkin's lymphomas. Simultaneous localization in the eyelid and in the breast, as observed in our case, is however exceptional.

CASE REPORT

Chronic lymphoid leukemia (CLL) was suspected in a 71-year-old woman with asthenia, a cervical and axillary nodal enlargement and elevated lymphocyte count. Blood immunoflow cytometry analysis, occurrence of rapidly growing tumors involving the two breasts and eyelids and cytogenetic and molecular features led to the diagnosis of MCL. A very good partial remission was obtained with second-line polychemotherapy composed of cytarabin, cisplatin and dexamethasone, but lasted only 3 months after the end of 6 cycles.

DISCUSSION

Primary breast and eyelid lymphomas are rare. Such localizations are exceptional in MCL and are signs of aggressive disease. Before extra-nodal involvement, MCL may simulate banal CLL. Therefore, systematic immunohistochemistry and if necessary molecular analysis are useful for early diagnosis of MCL. Prognosis is particularly poor. Conventional chemotherapy cannot provide cure of MCL and median survival is 48 months. For this reason, high-dose chemotherapy with stem cell graft has to be discussed in young patients. MCL is currently characterized by Bcl1 rearrangement, t(11-14) translocation and cyclin D1 overexpression among small B-cell lymphomas in recent REAL- and WHO-classifications.

[Association of celiac disease and esophageal small cell carcinoma]

BACKGROUND

Coeliac disease is known to favor the development of neoplasia. Coeliac disease associated with small-cell carcinoma of the esophagus has not been reported to date.

CASE REPORT

A 51-year-old man with coeliac disease known for several years was hospitalized for epigastric pain. Work-up led to the diagnosis of small-cell carcinoma of the lower esophagus. The patient was treated with 6 cycles of chemotherapy using an etoposide-ciplatinum protocol associated with 60 Gy radiotherapy starting at the third cycle. The patient has remained in complete remission 2 years after diagnosis.

DISCUSSION

Small-cell carcinoma of the esophagus is an exceptional finding in a patient with coeliac disease. Chemotherapy associated with radiotherapy has been successful in our patient.

Adult Still's disease. Part II. Management, outcome, and prognostic factors

DESIGN

a multicenter study conducted in France identified 65 cases of adult Still's disease. Follow-up exceeded one year in 52 cases.

OBJECTIVES

were as follows: 1) to describe treatments used; 2) to analyze disease course patterns; 3) to study joint alterations; 4) to determine whether any characteristics present within the first six months of onset were of prognostic significance.

RESULTS

aspirin was ineffective. Indomethacin ensured satisfactory control in eight patients. Corticosteroid therapy was required in 88% of cases. Among patients followed up for more than one year, half developed radiologic joint alterations; 23% had monocyclic systemic disease, 38.5% had polycyclic systemic disease and 38.5% had chronic articular disease. More than half of the patients (58%) had more than one systemic flare. Polyarthritis at onset and involvement of the proximal limb joints were significantly predictive of chronic articular disease, whereas isolated arthralgia was predictive of monocyclic or polycyclic systemic disease. Oligoarthritis was not predictive of the outcome.

CONCLUSION

the knowledge that polyarthritis or proximal limb joint involvement within six months of onset is predictive of chronic joint disease may have important therapeutic implications.

Adult Still's disease: part I. Manifestations and complications in sixty-five cases in France

DESIGN

a retrospective multicenter study conducted in France identified 65 cases of adult Still's disease. Data were recorded on a standardized questionnaire validated by the Inflammatory Joint Disease and Immunorheumatology Committee of the Société Française de Rhumatologie.

OBJECTIVES

(1) To compare clinical and laboratory findings in our patients with those reported in earlier studies, particularly two large series from Canada and Japan, respectively; (2) to describe the systemic and visceral complications associated with adult Still's disease.

RESULTS

as compared with the two above-mentioned series, our study group included more patients who had experienced onset of their disease after the age of 35 years and fewer patients with involvement of the liver, spleen, or lymph nodes. Rates of occurrence of arthritis, myalgia, sore throat, pleuritis, pericarditis, and abdominal pain were significantly higher in the Canadian series than in the other two series. Arthritis was absent in one fourth of our patients. Life-threatening complications included "Still's hepatopathy", disseminated intravascular coagulation (with hemophagocytosis in some cases), and "Still's myocarditis".

CONCLUSION

differences in the expression of adult Still's disease were found between patients from Canada, France, and Japan. Adult Still's disease can be responsible for life-threatening complications.

Amnion rupture in the second trimester

Two cases of amnion rupture are presented in 'low-risk' pregnancies. One case ended in fetal death in utero at 21 weeks. The other resulted in the preterm delivery of an otherwise normal male with mild amniotic band syndrome.

Epidemiology of adult Still's disease: estimate of the incidence by a retrospective study in west France

OBJECTIVES

To estimate the incidence of adult Still's disease (ASD) and to specify, if possible, associated factors.

METHODS

A retrospective study of the populations of the Brittany and Loire regions in west France was made from 1 January 1982 to 31 December 1991. All internal medicine and rheumatology practitioners of these regions were consulted.

RESULTS

Sixty-two (62) cases were reported (93% response). The disease incidence calculated over five years was 0.16 per 100,000 inhabitants in the study population. There was no sex bias (sex ratio 1.06 in ASD v 1.05 in the overall population. The mean age of the study population was 36 years, with two peaks of distribution at 15-25 and 36-45 years. A history of allergy was present in 23% of patients (n = 14). In two patients, it was possible to correlate an environmental allergen to exacerbation of ASD.

CONCLUSION

The yearly incidence of ASD was estimated to be 0.16 per 100,000 inhabitants. However, it was not possible to incriminate any infectious, toxic, or genetic factors in exacerbation of the disease.

Twin-twin transfusion syndrome: intraamniotic pressure measurement in the assessment of volume reduction at serial amniocenteses

Two cases of severe twin-twin transfusion syndrome are described. In both, serial amniocenteses were followed by resolution of the disordered inter-twin haemodynamics with 4 intact term survivors. In all reports to date of aggressive reduction with or without successful outcome, volume reduction has been dictated by subjective or semiquantitative ultrasonic estimates of liquor volume. With the use of intraamniotic pressure estimation we describe a more rational basis for the removal of these large volumes of amniotic fluid.

Importance of complete follow-up of spontaneous fetal loss after amniocentesis and chorion villus sampling

Women who are the most difficult to trace after amniocentesis or chorion villus sampling are often those who have had an adverse pregnancy outcome. To calculate total fetal loss figures for use in prenatal counselling we have followed in a multicentre study 100% of women who had undergone these procedures. Early spontaneous loss (within three weeks of the procedure) and total spontaneous loss were much lower after amniocentesis (0.2% and 1.3%, respectively) than after chorion villus sampling (1.2% and 2.9%). Four spontaneous fetal losses among the 20 pregnancies that were the most difficult to follow-up increased the loss rate by 0.5% for chorion villus sampling. Risk of early fetal loss after chorion villus sampling was related to experience of the operator (relative risk [RR] 4.3, p = 0.003), and total fetal loss was lower in pregnancies tested at 10 weeks' or more gestational age compared with those tested before 10 weeks' (RR 0.4, p = 0.01). A table showing the frequency of each of the seven possible outcomes after amniocentesis and chorion villus sampling is useful in counselling those considering one or other test.

Maintenance of Pregnancy and Obstetric Outcome in Donor Egg Pregnancies

Data are presented on the outcome of 43 pregnancies between 1983 and 1991. Maintenance of pregnancy in agonadal women begins at the time of embryo implantation, and initial hormone replacement therapy to prime the endometrium before embryo transfer is an important factor. Synchronization in agonadal women is successful with the variable-length oestrogen replacement regime but can be difficult in ovulating recipients. The outcome of donor egg (DE) pregnancies in this study is comparable to that of IVF pregnancies, with the possible exception of an increased rate of monozygous twins. Pre-eclampsia does not appear to increase significantly in DE pregnancies. Vaginal delivery is possible for DE pregnancies in women with ovarian failure.

Intensive treatment of stage III-IV aggressive malignant lymphomas (protocol TPL-84)

BACKGROUND

Much progress has been made in the last ten years in the treatment of non Hodgkin's lymphomas by increasing drug schedules and by using non cross-resistant regimens.

METHODS

So we decided in 1984 to test a new multiple drug protocol (Tours-Poitiers-Limoges = TPL protocol) which used a sequence of three courses of classical high-dose induction therapy, three courses of consolidation therapy using Teniposide, Cytosine Arabinoside, L Asparaginase and high-dose Methotrexate, and three courses of late intensification using the same drugs as induction therapy. Results. Thirty-eight patients younger than 60 years were included. Complete remission was obtained in 27 patients (71%). The median follow-up was 3 years and 9 months with one third of CR patients having been followed beyond 5 years. Seven patients relapsed (26% of CR patients) and one died of toxicity in complete remission. At present 22 patients (58%) are in complete remission, 19 in first CR, 1 in first CR after allogenic bone marrow transplantation, and 2 in second prolonged CR after autologous bone marrow transplantation. The median survival time is 48 months and the actuarial disease-free survival curve seems to have a plateau at 48.5%, with no relapse after 24 months.

CONCLUSIONS

These results confirm the efficacy of alternating high-dose conventional chemotherapy in the treatment of intermediate and high-grade NHL, with about half of the patients being cured. However, more intensive chemotherapy regimens are needed to improve cure rates.

A comparison of vaginal ultrasonic-guided and laparoscopic retrieval of oocytes for in vitro fertilization

A retrospective analysis was undertaken to compare the less invasive technique of vaginal ultrasonic-guided oocyte retrieval with the standard laparoscopic technique. We have shown that the outcome of the transvaginal technique with respect to oocytes harvested, fertilization rate, and pregnancy rate is comparable with the laparoscopy technique. We have also shown that 9 clinicians with little previous expertise in ultrasound have been able to incorporate this technique into a busy and successful in vitro fertilization unit.

[Splenectomy can cure thrombocytopenia of systemic lupus erythematosus]

Between 1976 and 1988, 7 patients with systemic lupus erythematosus (SLE) underwent splenectomy for severe peripheral thrombocytopenia (platelet count below 30,000/mm3) which had resisted corticosteroid therapy (n = 7), high-dose immunoglobulins (n = 4), vincristine (n = 2), danazol (n = 1), cyclophosphamide and plasma exchanges (n = 1). No infective or non-infective complication of splenectomy was observed. One patient died of intracerebral haemorrhage 3 years later, after several recurrences of thrombocytopenia. The 6 survivors have normal platelet counts (more than 150,000/mm3) after splenectomy, over a mean follow-up period of 80 months. Two of these 6 patients never had recurrent thrombocytopenia and have not received any treatment for 17 to 102 months. Four patients are still under prednisone in doses lower than 30 mg/day. Among these, 2 had recurrent thrombocytopenia 2 and 60 months respectively after splenectomy and responded favourably to another course of corticosteroids associated, in one case, with cyclophosphamide. Thus, splenectomy is an effective treatment of the thrombocytopenia associated with SLE. However, the possibility of early or late recurrences makes it necessary to reserve splenectomy to those cases where medical treatment has failed or is contra-indicated.

Transvaginal recovery of oocytes for in vitro fertilization using vaginal ultrasound

Vaginal recovery of oocytes for in vitro fertilization (IVF) was performed in 75 patients using a vaginal puncture transducer. Follicles were aspirated and flushed four times using a controlled vacuum. Oocytes were collected in 74 patients and an average of 5.1 oocytes was collected per patient. An average of 8.8 follicles was aspirated per procedure, giving an oocyte recovery rate of 58% per follicle. Pregnancy was obtained in seven patients (9.3%). The only complication was bleeding from the vagina of an estimated 40 ml in one case.

A failed RCT to determine the best method of delivery for very low birth weight infants

An RCT to determine the optimum method of delivery for very low birth weight (VLBW) infants was canceled after it had been in progress for only 5 months when it was discovered that more than 40% of eligible patients were being withdrawn from the trial before randomization. A review of hospital births before the trial began suggested that the trial was held too late: that a critical shift in obstetric practice towards abdominal delivery of VLBW infants had already occurred. Obtaining patient consent to participation, which had been the main predicted problem, was not difficult.