Cardiac amyloidosis is not a single disease: a multiparametric comparison between the light chain and transthyretin forms

Background

Systemic amyloidoses represent a heterogeneous group of diseases resulting from the deposition of misfolded proteins as amyloid fibrils into the extracellular matrix of different organs. Based on this precursor protein, cardiac amyloidosis (CA) can be most frequently classified as: light chain (AL) and transthyretin (ATTR) amyloidosis, with different management and prognosis.

Purpose

The purpose of this study is to establish a differential diagnosis algorithm targeted towards these two most frequent subtypes of CA. Although confirmation through invasive or non-invasive diagnostic algorithms is still mandatory for a final diagnosis, a series of clinical, paraclinical and imaging differences could possibly guide the choice for more complex diagnostic steps.

Methods

We prospectively included all consecutive patients with ATTR and AL evaluated between 2018 and 2022 in our center. All patients had a complete clinical, paraclinical and imaging evaluation including myocardial deformation study, and confirmation of the final diagnosis, according to the current international recommendations.

Results

The study population included 81 patients divided into 2 groups: ATTR (group 1, n=32: 30 variant and 2 wild type) and AL (group 2, n=49).

ATTR patients were younger (50.7±13.9 vs. 60.2±7.3 years, p=0.0001), had predominantly more neurological symptoms, milder cardiac symptoms and lower values of cardiac biomarkers than AL: NT-proBNP (3095±4433 vs. 10382±9008 ng/ml, p=0.001) and high sensitive troponin I (0.0129±0.01 vs 0.177±0.2 ng/ml, p=0.0002), with better renal function (mean GFR 84.74±26.9 vs. 64.5±29.45 mL/min, p=0.003). We found no significant differences in terms of ECG changes.

Moreover, at similar left ventricular (LV) wall thickness and ejection fraction, ATTR group had less pericardial effusions (53.6 vs. 86.8%, p=0.0027), better LV global longitudinal strain (−12.0±3.7 vs. −9.7±4.6%, p=0.03), RV strain (RVFW strain −19.7±6.2 vs. −14.5±11.0%, p=0.03) and also better reservoir and contractile function of the LA (LASr 17.2±12.3 vs. 11.2±7.4%, p=0.02).

Based on this multiparametric comparison we proposed a prediction algorithm to differentiate between the 2 forms of CA. A score of equal or more than 4 from a maximum of 9 points, has been able to differentiate between AL and ATTR with a sensitivity and specificity of 78 and 80%, respectively; AUC= 0.82.

Conclusions

CA is a complex entity and requires extensive testing through serum biomarkers, imaging, and invasive confirmation of amyloid infiltration in some cases. This study highlighted a series of non-invasive checkpoints, which can be useful in guiding the decision making process towards a more accurate and rapid differential diagnosis, in cases where a final diagnosis is crucial to be immediately established.

Funding Acknowledgement

Type of funding sources: None.

P216 Cardiac amyloidosis is not a single disease: an echocardiographic study of light chain vs transthyretin forms

Background

Cardiac amyloidosis (CA) is described as one entity. However, several subtypes of amyloid can infiltrate the heart: light chain (AL) and tranthyretin (ATTR) are the most common.

Purpose

To characterize the specific findings of the CA subtypes as a tool to aid differential diagnosis between AL and ATTR CA.

Material and methods: Consecutive patients with CA were evaluated by clinical examination, ECG, cardiac biomarkers and echocardiography with both conventional and myocardial deformation study of the left ventricle (LV), left atrium (LA) and right ventricle (RV). Amyloid subtype was described using light chain assessment for AL-CA and 99Tc-HMPD scintigraphy and TTR gene sequencing for ATTR-CA.

Results

32 patients with CA were included, 13 with ATTR and 19 with AL. Patients in AL group were significantly older, with higher levels of cardiac biomarkers. At similar LV EF and wall thickness, they had lower GLS. LA function parameters were also lower in AL pts (table). Using ROC curves, the best predictors for AL diagnosis were NTproBNP (AUC 0.937) and Tn levels (AUC 0.958), as well as LV GLS and pericardial fluid presence (both AUC 0.750).

Conclusions

At similar LV wall thickness and ejection fraction, cardiac dysfunction appears to be more severe in AL pts, with lower global LV longitudinal strain, worse LA function, higher sPAP and NTproBNP.

ATTR (13 pts) AL (19 pts) p Age (years) 50 ± 12 60 ± 8 0.01 NTproBNP (pg/mL) 3066 ± 3720 11755 ± 9114 0.02 hsTnI (ng/mL) 0.005 ± 0.008 0.147 ± 0.161 0.04 Pericardial fluid (%) 53% 100% 0.002 LVEDV (mL) 88 ± 25 75 ± 38 NS LVMi (g/m2) 166 ± 47 168 ± 41 NS LVEF (%) 50 ± 8 49 ± 16 NS LV GLS (%) -12.1 ± 3.8 -8.9 ± 4.5 0.04 Septal Basal/Apical LS 0.33 ± 0.17 0.25 ± 0.27 NS LAVi (mL/m2) 46 ± 21 45 ± 14 NS LAEF 4CV (%) 35 ± 21 24 ± 8 0.05 LA systolic strain (%) 17.4 ± 11.9 10.5 ± 5.0 0.02 RV free wall thickness (mm) 7.0 ± 1.5 7.6 ± 1.4 NS RV 6-segments strain (%) -15 ± 4 -10 ± 8 0.09 sPAP (mmHg) 36.6 ± 12.0 48.6 ± 17.2 0.04

THERAPEUTIC PARTICULARITIES OF CHRONIC SUPPURATED CHOLESTEATOMATOUS OTOMASTOIDITIS

Chronic suppurated otomastoiditis is a chronic inflammatory damage of the middle ear and mastoid process that exceeds 12 weeks and which leads to the permanent perforation of the eardrum’s membrane. There is local damage such as osteitis, osteonecrosis and cholesteatoma, while a general view reveals an  asymptomatic evolution, with a good general state, otorrhea being the only local symptom. This paper brings to light a case resulting from the thorough analysis of case studies run by the ENT Clinic of the Emergency County Hospital "Sf. Apostol Andrei” of Galaţi, through the fact that otomastoiditis progresses given the presence of a congenital hemangioma located on the left half of the cephalic extremity, at a cervical, thoracic and abdominal level. The patient, aged 41, has been suffering from this disease since childhood and has undergone numerous surgeries up to this moment, but none has proven to be adequate for the extent of the lesion due to the malformation and the difficulty in providing general anesthesia with orotracheal intubation, the hemangioma being present in the oropharynx, hypopharynx and larynx. Given the overlapping of the two disorders, the surgical-medical approach to the ear damage has proven insufficient in time due to the risk of massive bleeding, taking into account the fact that the hemangioma was extended to the left ear duct, pharynx and larynx. For this reason, the disease has progressed, leading to extended erosive cholesteatoma with left otomastoiditis. The particularities of the therapeutic approach are presented along with anesthesiologic and surgical problems involved by the hemangioma. Although the risk of hemorrhaging was great, approaching the condition by choosing to provide general anesthesia and making the incisions only with the help of an electric scalpel, the case was eventually solved successfully from a surgical point of view.

Nonlinear analysis of saccade speed fluctuations during combined action and perception tasks

BACKGROUND

Saccades are rapid eye movements used to gather information about a scene which requires both action and perception. These are usually studied separately, so that how perception influences action is not well understood. In a dual task, where the subject looks at a target and reports a decision, subtle changes in the saccades might be caused by action-perception interactions. Studying saccades might provide insight into how brain pathways for action and for perception interact.

NEW METHOD

We applied two complementary methods, multifractal detrended fluctuation analysis and Lempel-Ziv complexity index to eye peak speed recorded in two experiments, a pure action task and a combined action-perception task.

RESULTS

Multifractality strength is significantly different in the two experiments, showing smaller values for dual decision task saccades compared to simple-task saccades. The normalized Lempel-Ziv complexity index behaves similarly i.e. is significantly smaller in the decision saccade task than in the simple task.

COMPARISON WITH EXISTING METHODS

Compared to the usual statistical and linear approaches, these analyses emphasize the character of the dynamics involved in the fluctuations and offer a sensitive tool for quantitative evaluation of the multifractal features and of the complexity measure in the saccades peak speeds when different brain circuits are involved.

CONCLUSION

Our results prove that the peak speed fluctuations have multifractal characteristics with lower magnitude for the multifractality strength and for the complexity index when two neural pathways are simultaneously activated, demonstrating the nonlinear interaction in the brain pathways for action and perception.

Clinical study on cervical phlegmons

The purpose of this paper is to develop an algorithm for the diagnosis and treatment of cervical phlegmons in order to increase the diagnostic accuracy, to reduce the intra and postoperative risks and complication rates and to increase the number of cases with restitutio ad integrum. This is a retrospective clinical study on 21 patients diagnosed with cervical phlegmon. The study group consists of patients with lateral and retropharyngeal phlegmon (18 cases, of which two pharyngeal or cervical oesophagus effractions by foreign body- chicken or fish bone - with pneumomediastinum), retropharyngeal abscess and posttraumatic mediastinal (one case),peritonsillar phlegmon fused in the parapharyngeal space complicated by parapharyngeal haemorrhage after spontaneous drainage of purulent collections (2 cases). Surgical treatment was applied in all cases, associated with intravenous antibiotic medication; the treatment was individualized according to the particularities of each case: the location and extent of the phlegmon, complications, duration of evolution, mechanisms of production, etiology, associated general conditions, age and, not least, the patient's choice.

Evidence for superfluidity of ultracold fermions in an optical lattice

The study of superfluid fermion pairs in a periodic potential has important ramifications for understanding superconductivity in crystalline materials. By using cold atomic gases, various models of condensed matter can be studied in a highly controllable environment. Weakly repulsive fermions in an optical lattice could undergo d-wave pairing at low temperatures, a possible mechanism for high temperature superconductivity in the copper oxides. The lattice potential could also strongly increase the critical temperature for s-wave superfluidity. Recent experimental advances in bulk atomic gases include the observation of fermion-pair condensates and high-temperature superfluidity. Experiments with fermions and bosonic bound pairs in optical lattices have been reported but have not yet addressed superfluid behaviour. Here we report the observation of distinct interference peaks when a condensate of fermionic atom pairs is released from an optical lattice, implying long-range order (a property of a superfluid). Conceptually, this means that s-wave pairing and coherence of fermion pairs have now been established in a lattice potential, in which the transport of atoms occurs by quantum mechanical tunnelling and not by simple propagation. These observations were made for interactions on both sides of a Feshbach resonance. For larger lattice depths, the coherence was lost in a reversible manner, possibly as a result of a transition from superfluid to insulator. Such strongly interacting fermions in an optical lattice can be used to study a new class of hamiltonians with interband and atom-molecule couplings.

Membrane sweeping for induction of labour

BACKGROUND

Sweeping of the membranes, also named stripping of the membranes, is a relatively simple technique usually performed without admission to hospital. During vaginal examination, the clinician's finger is introduced into the cervical os. Then, the inferior pole of the membranes is detached from the lower uterine segment by a circular movement of the examining finger. This intervention has the potential to initiate labour by increasing local production of prostaglandins and, thus, reduce pregnancy duration or pre-empt formal induction of labour with either oxytocin, prostaglandins or amniotomy. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

OBJECTIVES

To determine the effects of membrane sweeping for third trimester induction of labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (6 July 2004) and bibliographies of relevant papers.

SELECTION CRITERIA

Clinical trials comparing membrane sweeping used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods.

DATA COLLECTION AND ANALYSIS

A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction.

MAIN RESULTS

Twenty-two trials (2797 women) were included, 20 comparing sweeping of membranes with no treatment, three comparing sweeping with prostaglandins and one comparing sweeping with oxytocin (two studies reported more than one comparison). Risk of caesarean section was similar between groups (relative risk (RR) 0.90, 95% confidence interval (CI) 0.70 to 1.15). Sweeping of the membranes, performed as a general policy in women at term, was associated with reduced duration of pregnancy and reduced frequency of pregnancy continuing beyond 41 weeks (RR 0.59, 95% CI 0.46 to 0.74) and 42 weeks (RR 0.28, 95% CI 0.15 to 0.50). To avoid one formal induction of labour, sweeping of membranes must be performed in eight women (NNT = 8). There was no evidence of a difference in the risk of maternal or neonatal infection. Discomfort during vaginal examination and other adverse effects (bleeding, irregular contractions) were more frequently reported by women allocated to sweeping. Studies comparing sweeping with prostaglandin administration are of limited sample size and do not provide evidence of benefit.

AUTHORS' CONCLUSIONS

Routine use of sweeping of membranes from 38 weeks of pregnancy onwards does not seem to produce clinically important benefits. When used as a means for induction of labour, the reduction in the use of more formal methods of induction needs to be balanced against women's discomfort and other adverse effects.

Cervical cancer in pregnant women: laparoscopic evaluation before delaying treatment

BACKGROUND

Cervical carcinoma diagnosed during pregnancy generates conflicting concerns between control of malignancy and continuation of pregnancy.

CASE

An invasive cervical carcinoma FIGO Stage IB2 was diagnosed in a 33-year-old primigravida during the first trimester of pregnancy. Because the patient strongly desired to preserve her pregnancy, laparoscopic lymphadenectomy was performed at 16 weeks of gestation to determine the extension of disease. Negative lymph node status was found and the patient was counseled about the possibility of proceeding until adequate fetal maturity had been achieved. An elective cesarean section and radical hysterectomy were performed at 36 weeks, followed by postoperative chemoradiation therapy. The clinical and Pap smear follow-up remain normal after four years.

CONCLUSION

Pregnant women diagnosed with early stage cervical carcinoma should receive a complete evaluation including lymphadenectomy before considering delayed therapy. This strategy seems to be an acceptable option in well-defined conditions, and offers these patients the possibility of maternity.

Intraobserver and interobserver agreement in the diagnosis of anal sphincter tears by postpartum endosonography

OBJECTIVE

To evaluate intraobserver and interobserver agreement in the diagnosis of anal sphincter tears by endosonography when performed immediately postpartum by resident obstetricians.

METHODS

Fifty-four primiparous women who delivered vaginally and had no anal sphincter tears (third- or fourth-degree perineal tears) diagnosed clinically were recruited. Four observers assessed photographic prints and video recordings of anal endosonography performed before the suture of the perineum. We calculated the intra- and interobserver agreement and the kappa coefficient to quantify the reliability of the diagnosis of clinically occult sphincter tears.

RESULTS

The observers described sphincter tears in 13-28% of the prints, and in 7-32% of the video recordings. Intraobserver agreement was rated as substantial for prints (kappa, 0.63), and moderate for video recordings (kappa, 0.48). The interobserver agreement was fair for prints (kappa, 0.34) and moderate for video recordings (kappa, 0.42).

CONCLUSION

Endosonography performed immediately postpartum to diagnose anal sphincter tears is of moderate reliability.

[Hereditary, recurrent corneal erosions]

The review presents a clinical case of 40 years old female patient with bilateral recurrent corneal erosions (r.c.e.), without an obvious cause. It is relevant to mention the present of the r.c.e. in her family during 4 generations. The acute corneal lesions looked like a "map-dot-fingerprint" dystrophy and 3 weeks later cornea became normal.

[Fuchs's syndrome or Eales's disease ?]

The authors report a female patient case presenting anterior signs of Fuchs' Syndrome (iris heterochromic, keratitis precipitates) as well as signs of Eales' Disease (proliferative retinopathy, peri-vasculitis).

Hydration for treatment of preterm labour

BACKGROUND

Hydration has been proposed as a treatment for women with preterm labour. Theoretically, hydration may reduce uterine contractility by increasing uterine blood flow and by decreasing pituitary secretion of antidiuretic hormone and oxytocin.

OBJECTIVES

To evaluate the effectiveness of intravenous or oral hydration to avoid preterm birth and its consequences in women with preterm labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register (January 2002), the Cochrane Controlled Trials register (The Cochrane Library, Issue 1, 2002) and bibliographies of relevant papers were searched.

SELECTION CRITERIA

Randomised controlled trials, including women with a viable pregnancy less than 37 completed weeks' gestation and presenting with preterm labour, comparing intravenous or oral hydration with no treatment. The intervention might or might not be associated with bed rest. Studies comparing tocolytic drugs with intravenous fluids used in the control group as a placebo were not included in this review.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the reports, to determine if the study met the inclusion criteria and to evaluate the methodological quality. Data were extracted independently by two of the reviewers. The results were expressed as relative risks (RR) for dichotomous outcomes and weighted mean difference for continuous outcomes.

MAIN RESULTS

Two studies, including a total of 228 women with preterm labour and intact membranes, compared intravenous hydration with bed rest alone. Risk of preterm delivery, before 37 weeks (relative risk (RR): 1.09; 95% confidence interval (CI): 0.71-1.68), before 34 weeks (RR: 0.72; 95% CI: 0.20-2.56) or before 32 weeks (RR: 0.76; 95% CI: 0.29-1.97), was similar between groups. Admission to neonatal intensive care unit occurred with similar frequency in both groups (RR: 0.99; 95% CI: 0.46-2.16). Cost of treatment was slightly higher (US$39) in the hydration group. This difference was not statistically significant and only includes hospital costs during a visit of less than 24 hours. No studies evaluated oral hydration.

REVIEWER'S CONCLUSIONS

The data are too few to support the use of hydration as a specific treatment for women presenting with preterm labour. The two small studies available do not show any advantage of hydration compared to bed rest alone. Intravenous hydration does not seem to be beneficial, even during the period of evaluation soon after admission, in women with preterm labour. Women with evidence of dehydration may, however, benefit from the intervention.

[Anatomic and physiopathologic basis for the diagnosis and treatment of intestinal ischemia]

Changes of circulatory parameters in splanchnic territory lead to gut ischemia in an acute or chronic form (postprandial abdominal stroke). The implicated factors in intestinal ischemia are the timing and kind of onset, countercurrent vascularization and the eventuality of anastomotic subsystems for becoming hypertrophic. Superior mesenteric artery (SMA) is the "key" blood vessel implicated in the production of chronic intestinal ischemia, the atherosclerotic lesion being localized more frequent near SMA's ostium or even at ostium itself. Nonoclusif ischemia is induced by another stimulus that provokes mesenteric vasoconstriction, status that affects more the antimesenteric intestinal border, with a larger expansion at mucosa level. The most reseed diagnostic methods are selective angiographies and ultrasound examination. Usually chronic intestinal ischemia is clinically asymptomatic and becomes clinical evident just in the presence of an acute superposed factor or when at least two digestive arteries are affected. Revascularization methods are different, based on the type, mechanism and site of obstruction, each with its advantages and disadvantages. The most used method is retrograde aortomesenteric by-pass, at infrarenal aortic level (that is more accessible than the supraceliac aorta) and SMA reimplantation.

[Correlations between the type of distribution of the branches of the inferior mesenteric artery and the aspect of the mesocolon]

Emergence pattern of inferior mesenteric artery (IMA) branches leaded to description of 6 types of arterial distribution, each of them being correlated with a certain mesocolon aspect. The height of mesosigmoid depends on coalescence pattern and grade, and has a particular importance in terminal colic and retroperitoneal viscera's surgery. For each of the 6 types of distribution are described different ways of differential ligatures, for elongation and descending the colon, initially establishing the predominant collateral trunks. For practicing these ligatures we have to take count of preoperative paraclinic investigations, general and particular haemodynamic conditions and some intraoperatory parameters.

[The influence of meteorological factors for frequency of Herpes simplex keratitis]

HYPOTHESIS

The variation of the meteorological factors could be a stress for the organism, which could determine the start of some diseases.

MATERIAL AND METHOD

We studied 252 cases of herpes simplex keratitis which had been hospitalized in Eye Clinic of Cluj between 1983-1991. The selection criteria were: known diagnosis; day of the rise could be exactly established; disease was taken place in Cluj or in region not longer than 30 km on Somes Valley. The meteorological parameters were collected by specialist from the Meteorological Station of the city and from the Cluj's Airport. The results were verified statistical and were guaranted by p = 0.05.

RESULTS

The herpes simplex keratitis are more frequently in days with a temperature higher and an atmospheric pressure lower than the average value of the season.

DISCUSSIONS

We drew a possible pathogenic mechanism to explained the reactivation of the virus under the influence of warm weather.

[The influence of meteorological factors in wintertime on the incidence of the occurrence of acute endogenous iridocyclitis]

PURPOSE

I tried to establish if the atmospheric factors such as: temperature, pressure, humidity of the air, wind, had any influence on the onset of acute uveitis.

METHOD

This study was made on 597 cases with acute uveitis hospitalized in the Eye Clinic--Cluj-Napoca, between 1983-1991.

CONCLUSION

During winter, in the region of Cluj, acute uveitis occurred significantly more often: 1. When the weather was warmer or colder than the mean value of the season, and the temperature varied with more than 4 degrees C from the previous day; 2. When the humidity of the air was low (dry weather); 3. When the wind was more than 4 m/s. Correlating the physiological knowledge with the studies about weather and the living organisms, I draw some possible pathogenetic mechanisms to explain the influence of the meteorological factors on the onset of acute uveitis, in winter.

[The significance of points alpha and beta on the dark adaptogram of the normal eye]

PURPOSE

To determine the meaning of the points alpha and beta of the curve during dark adaptation.

METHOD

In this paper I studied the curves during dark adaptation of the 48 normal eyes, examined at the Goldmann-Weekers adaptometer, for 30 minutes in standard conditions. The study had two stages: 1. To find out the mathematical low which defined the phenomenon; 2. To give a physiological explanation of the phenomenon.

CONCLUSIONS

1. Distribution in time of point alpha and point beta recognized mathematical low of normal log. 2. The cones adapted to the dark into two phases: from the beginning of the adaptation to the point alpha; after point alpha till before point beta. 3. The rods adapted in three phases: a) before point alpha to the point alpha; b) from point alpha to the point beta; c) after point beta to the terminal threshold.

CONCLUSION

Point beta gained a new meaning: point beta represents the end of the cone's adaptation.

[Orbital tuberculoma]

We present a case of orbital tumor with skin lesions at the lateral cantus. CT scan confirmed the orbital tumor and we considered it to be malignant. The histological examination of a piece of the tumor showed tuberculous characteristics. Patient received treatment with antituberculous drugs and steroids. The tumor decreased after two months of treatment.

Mechanical methods for induction of labour

BACKGROUND

Mechanical methods were the first methods developed to ripen the cervix or to induce labour. Devices which were used include various type of catheters and of laminaria tents, introduced into the cervical canal or into the extra-amniotic space. Mechanical methods were never completely abandoned, but were substituted by pharmacological methods during recent decades. Potential advantages of mechanical methods, compared with pharmacological methods, may include simplicity of preservation, lower cost and reduction of the side effects. However, special attention should be paid to contraindications (e.g. low-lying placenta), risk of infection and maternal discomfort when inserting these devices. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

OBJECTIVES

To determine the effects of mechanical methods for third trimester cervical ripening or induction of labour in comparison with placebo/no treatment, prostaglandins (vaginal, intracervical, misoprostol) and oxytocin.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group Trials Register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched April 2001.

SELECTION CRITERIA

The criteria for inclusion were the following: (1) clinical trials comparing mechanical methods used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate or unclear method for allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions.

DATA COLLECTION AND ANALYSIS

A strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally, and incorporated into a series of primary reviews arranged by methods of induction of labour, following a standardised methodology. The data will be extracted from the primary reviews into a series of secondary reviews, arranged by category of woman.

MAIN RESULTS

In total, 58 studies were considered; 45 studies have been included and 13 were excluded. Studies generally included women with unfavourable cervix and intact membranes. Comparing mechanical methods with placebo/no treatment, only one study with 48 participants reported on vaginal delivery not achieved in 24 hours (69% with mechanical methods versus 77% with placebo/no treatment; relative risk (RR) 0.90; 95% confidence interval (CI): 0.64-1.26). Hyperstimulation with fetal heart rate changes was not reported. The risk of caesarean section, reported in six studies including 416 women, was similar between groups (34%; RR 1.00; 95% CI: 0.76-1.30). There were no reported cases of severe neonatal and maternal morbidity. Comparing mechanical methods with vaginal PGE2, only one trial (109 women) reported on vaginal delivery not achieved in 24 hours (73% versus 42%; relative risk (RR) 1.74; 95% CI: 1.21-2.49). Compared with intracervical PGE2, only one trial (100 women) reported on vaginal delivery not achieved in 24 hours (68% versus 40%; relative risk (RR) 1.70; 95% CI: 1.15-2.51). Compared with with misoprostol, the effectiveness of mechanical methods was similar (34% versus 30%; relative risk (RR) 1.15; 95% CI: 0.80-1.66). The use of mechanical method reduced the risk of hyperstimulation with fetal heart rate changes when compared with prostaglandins: vaginal PGE2 (0% versus 6%; RR 0.14; 95% CI: 0.04-0.53), intracervical PGE2 (0% versus 1%; RR 0.21; 95% CI: 0.04-1.20) and misoprostol (4% versus 9%; RR 0.41; 95% CI: 0.20-0.87). There was no difference in the risk of caesarean section between mechanical methods and prostaglandins. Serious neonatal (three cases) and maternal morbidity (one case) were infrequently reported. When compared with oxytocin, use of mechanical methods reduced the risk of caesarean section (4 trials; 198 women; 17% versus 32%; RR 0.55; 95% CI: 0.33-0.91). The likelihood of vaginal delivery in 24 hours and of hyperstimulation with fetal heart rate changes was not reported. There were no reported cases of serious maternal morbidity and severe neonatal morbidity was not reported. These results are similar whatever specific mechanical method was used, except with extra-amniotic infusion. When comparing extra-amniotic infusion with any prostaglandins, women were more likely to not achieve vaginal delivery within 24 hours (57% versus 42%; RR 1.33; 95% CI: 1.02-1.75), the risk of caesarean section was increased (31% versus 22%; RR 1.48; 95% CI: 1.14-1.90), without a reduction of the risk of hyperstimulation.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to evaluate the effectiveness, in terms of likelihood of vaginal delivery in 24 hours, of mechanical methods compared with placebo/no treatment or with prostaglandins. The risk of hyperstimulation was reduced when compared with prostaglandins (intracervical, intravaginal or misoprostol). Compared to oxytocin in women with unfavourable cervix, mechanical methods reduce the risk of caesarean section. There is no evidence to support the use of extra-amniotic infusion.

Diagnosis of anal sphincter tears by postpartum endosonography to predict fecal incontinence

OBJECTIVE

To determine whether anal endosonography immediately after vaginal delivery can predict subsequent fecal incontinence.

METHODS

We studied nulliparas who delivered vaginally and had no anal sphincter tears (third- or fourth-degree perineal tears) diagnosed clinically by endosonography before any suture of the perineum. The sonographer was unaware of delivery details and the obstetrician and the women were not informed of endosonography results. Therefore, the suture of the perineum and the outcomes were not influenced by sonographer's diagnoses. Three months after delivery, we assessed fecal incontinence by self-administered questionnaires.

RESULTS

Clinically undetected tears of the anal sphincter were diagnosed by anal endosonography in 42 of 150 women (28%). The external anal sphincter alone was involved in 30 women (20%), the internal anal sphincter alone in two (1.3%), and both in ten (7%). The postal questionnaire was returned by 144 women. Incontinence was reported by 22 (15%, 95% confidence interval [CI] 10%, 22%), consisting mainly of incontinence to flatus only (16 of 22, 73%, 95% CI 50%, 89%). Clinically undetected anal sphincter tears diagnosed by endosonography were associated with incontinence 3 months after delivery (odds ratio [OR] 8.8; 95% CI 2.9, 26.5). The sensitivity of anal endosonography was 68% (95% CI 49%, 88%) and the positive predictive value 37% (95% CI 22%, 51%).

CONCLUSION

Anal endosonography immediately after vaginal delivery allows diagnosis of clinically undetected anal sphincter tears that might be associated with subsequent fecal incontinence.

[Immunoglobulins in the tear secretion in cases of herpetic keratitis]

The goal of this study is to analyse the immunoglobulins of patients with herpetic keratitis. Tears have been collected from 36 patients with herpetic keratitis (study group) and 20 healthy volunteers (control group). Quantitative determination of A, G, M immunoglobulins and secretor IgA has been performed by Mancini radial immunodiffusion method. Our study has revealed the following results: a decrease in IgM and IgA levels compared with control group (p < 0.01) and an increase in secretory IgA compared with fellow eye (p < 0.05) in patients with herpetic keratitis of the first manifestation; eyes with recidivant herpetic keratitis showed higher level of IgA than the control group (p < 0.01) and a higher level of IgG than the first disease manifestation group (p < 0.05); the IgA level in the healthy eye of the patients with herpetic keratitis appeared significantly lower than in the control group (p < 0.001).

Stripping/sweeping the membranes for inducing labour or preventing post-term pregnancy

BACKGROUND

Stripping or sweeping of the membranes aims to initiate labour through a cascade of physiological events. These may reduce pregnancy duration or pre-empt formal induction of labour with either oxytocin, prostaglandins or amniotomy.

OBJECTIVES

The objective of this review was to assess the effects of membrane sweeping to promote or induce labour on maternal and perinatal outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register (last searched April 1998).

SELECTION CRITERIA

Adequately controlled trials of digital separation of the membranes from the lower uterine segment for inducing labour or for preventing post-term pregnancy, compared to either no vaginal examination or vaginal examination for cervical assessment only without the intention to detach the membranes.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed trial quality and extracted data.

MAIN RESULTS

Fourteen trials were included. Sweeping of the membranes, performed as a general policy in women at term, was associated with reduced duration of pregnancy and the frequency of pregnancy continuing beyond 41 weeks (relative risk 0.42, 95% confidence interval 0.19 to 0.93, random effects model) and 42 weeks. After sweeping of the membranes, there was a 17% risk reduction (confidence interval 6 to 29%, random effects model) in the use of more formal methods for labour induction. There was no difference in the mode of delivery or in the risk of infection. Discomfort during vaginal examination and other adverse effects (bleeding, irregular contractions) were more frequently reported by women allocated to sweeping.

REVIEWER'S CONCLUSIONS

Routine use of sweeping of membranes from 38 weeks of pregnancy onwards does not seem to produce clinically important benefits. When used as a means for induction of labour, the reduction in the use of more formal methods of induction needs to be balanced against women's discomfort and other adverse effects.

Elective delivery in diabetic pregnant women

BACKGROUND

In pregnancies complicated by diabetes the major concerns during the third trimester are fetal distress and the potential for birth trauma associated with fetal macrosomia.

OBJECTIVES

The objective of this review was to assess the effect of a policy of elective delivery, as compared to expectant management, in term diabetic pregnant women, on maternal and perinatal mortality and morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register (last searched July 1999).

SELECTION CRITERIA

All available randomized controlled trials of elective delivery, either by induction of labour or by elective caesarean section, compared to expectant management in diabetic pregnant women at term.

DATA COLLECTION AND ANALYSIS

The reports of the only available trial were analysed independently by the three co-reviewers to retrieve data on maternal and perinatal outcomes. Results are expressed as relative risks (RR) and 95% confidence intervals (CI).

MAIN RESULTS

The participants in the one trial included in this review were 200 insulin-requiring diabetic women. Most had gestational diabetes, except 13 women with type 2 preexisting diabetes (class B). The trial compared a policy of active induction of labour at 38 completed weeks of pregnancy, to expectant management until 42 weeks. The risk of caesarean section was not statistically different between groups (RR 0.81, 95% CI 0.52 - 1.26). The risk of macrosomia was reduced in the active induction group (RR 0.56, 95%CI 0.32 - 0. 98) and 3 cases of mild shoulder dystocia were reported in the expectant management group. No other perinatal morbidity was reported.

REVIEWER'S CONCLUSIONS

There is very little evidence to support either elective delivery or expectant management at term in pregnant women with insulin-requiring diabetes. Limited data from a single randomized controlled trial suggest that induction of labour in women with gestational diabetes treated with insulin reduces the risk of macrosomia. Although the small sample size does not permit one to draw conclusions, the risk of maternal or neonatal morbidity was not modified. Women's views on elective delivery and on prolonged surveillance and treatment with insulin should be assessed in future trials.

[Diagnostic and prognostic evaluations of sterility and the Sierre Hospital. 389 cases]

AIM OF THE STUDY

The management of infertile couples at regional hospital level is rarely reported and is generally less known, whereas the activity of university infertility clinics is usually the reference. We evaluate the diagnostic approach to infertile couples at the Regional Hospital of Sierre.

METHOD

The medical charts of 389 couples presenting with infertility between 1989 and 1996 were reviewed. The investigations and interpretation of results were always performed by the same investigator.

RESULTS

A lower pregnancy rate was observed in the case of a pathological postcoital test and when proximal tubal occlusion or phimosis were diagnosed by hysterosalpingography or laparoscopy. In our population, age of the female partner > 40 years, duration of infertility of more than 36 months and multifactorial, male and female, aetiology of infertility were significantly associated with a poor prognosis (p < 0.001). For the assessment of tubal patency, hysterosalpingography and laparoscopy with chromopertubation showed an acceptable level of agreement (kappa coefficient = 0.58). Hysterosalpingography does not provide a precise diagnosis in peritoneal and ovarian pathology (72.9% sensitivity, 55.7% specificity). A third of pregnancies were obtained without treatment during the diagnostic study of the menstrual cycle, or after hysterosalpingography and laparoscopy with chromopertubation.

CONCLUSION

Most diagnostic procedures for infertility can be performed in a regional hospital by an infertility specialist collaborating closely with a university centre. When infertile couples are transferred to a university centre their evaluation is simplified, as they have already completed an initial systematic investigation and treatment plan at the regional hospital. This two-step approach may be beneficial in selecting couples who need specific treatment not available in a regional hospital.

[Clinical effects of supplemental enteral nutrition solution in severe polytrauma]

Previous studies in critically ill patients have shown the beneficial effects of early enteral nutrition supplemented with arginine, omega-3 fatty acids and nucleotides (Impact) on immunological response, infection rate and length of stay in hospital. No specific data exist for patients with severe multiple injury, who represent a high risk group for systemic inflammatory response syndrome (SIRS), septic complications and multiple organ failure (MOF). In this prospective, randomized, double-blind controlled clinical study on patients after severe trauma (ISS ca. 40) the primary study endpoints were incidence of SIRS and MOF [definitions according to Am Soc Crit Care Med (5) and Goris (23), Sauaia (43)]. Thirty-two patients enrolled in the study, and 29 were eligible for analysis: test (Impact) (n = 16), control (n = 13). Both groups were comparable according to age, body mass index and severity of trauma (PTS-test: 38.8 +/- 12.5, PTS-control: 40.8 +/- 15.5, ISS-test: 39.6 +/- 11.4, ISS-control: 40.5 +/- 9.2). Patients were randomized to receive either Impact (test) or an isonitrogenous isocaloric diet (control). Feeding was started on the 2nd day after trauma via endoscopically placed nasoduodenal or jejunal feeding tubes. The experimental diet was safe and well tolerated. During the 1st week the enteral feeding amount was about 2000 ml without significant difference. Test-fed patients developed SIRS significantly less frequently between day 1 and day 28 (8 vs 13.3; P < 0.05) and especially between day 8 and day 14 (3 vs 6.2; P < 0.001). In the control group the Goris score was significantly worse (P < 0.05) on days 3, 4, 6, 7, 10, 11, 16 and 17 and the Sauaia score on days 8, 9, 10 and 11 (P < 0.05; P < 0.01). Mortality rate did not significantly differ (test 2/16, control 4/13), nor did length of ICU or hospital stay. With regard to the acute-phase response, C-reactive protein was significantly lower on day 4 in the test group (test: 131 +/- 67 mg/l, control: 221 +/- 110 mg/l) as was fibrinogen on day 12 (6.6 +/- 1.4 vs 7.5 +/- 1.4 g/l) and day 14 (7.1 +/- 1.3 vs 7.8 +/- 0.8 g/l). No significant difference could be observed for CD4/CD8 ratio, CD45 isotope on activated T-cells and lymphocytic interleukin (II)-2-receptor- and II-6 level. However, HLA-DR antigen presentation on peripheral monocytes was significantly elevated on day 7 in the test group (P < 0.05). According to the results, arginine, omega-3 fatty acids and nucleotides-enriched diet during early enteral feeding leads to reduction of SIRS after severe multiple injury. There is evidence for improvement of post-traumatic immunological response which helps to overcome the immunological depression after trauma.

[Behçet's disease with a fatal evolution]

Behçet disease in an inflammatory systemic disease, of unknown etiology. Usually it is defined by a triad; buccal ulcerations, genital ulcerations and uveitis. Treatment is based on steroids and in difficult cases cyclosporina or cytotoxic agents could be used. We present a case of Behçet disease in a young male. The first symptoms were retrobulbar optic neuropathy, followed by buccal and genital ulcerations. For beginning the treatment was based on steroids, but the disease was more and more severe, so that the left eye lost its function because of an inflammatory maculopathy and new symptoms arose. We started treatment with cyclosporina (5 mg/kg/day), but we had to stopped it 3 months latter because of renal function's failure.

[Intermesenteric anastomoses]

This work is based on dissection and the analysis of the arteriographies of two mesenteric arteries and it analyses the type of intermesenteric anastomoses and their importance in surgical practice. The morphological varieties of Riolan's arcade depends on its pillars, as well as on the eventual presence, especially in the middle part of the transversal mesocolon, of the secondary arcades; it seems that the colic wall necrosis depends less upon the location of the lesion or the level of the suture of the arcade, but more so on the stretch of the destruction of the mesocolon. The intermesenteric trunk, a second way of intermesenteric anastomoses is a embryological remaining, non-functional in normal conditions, but capable to partially or completely replace the Riolan's arcade when the later is sutured or interrupted.

Immune mechanisms in the process of hepatopathies chronicization. Contribution and role of lymphokines

The study attempts to evaluate the role of interleukin-6 (IL-6) in the pathogenesis of chronic hepatitis. We have used EIA sensitive methods to determine the serum concentration in patients with chronic active hepatitis of HB (+) (CAH-HE Ag+) antigen, with chronic active hepatitis of HB(-) (CAH-HBAg-) antigen and in those with persistent chronic hepatitis of HB(+) (CPH-HBAg+) antigen, compared with a group of controls (blood donors) in whom HBAgs, antiHBs, HBAge, antiHBe and anti HBc were absent. Disease status diagnosis was given in accordance with international conventions, immunologic tests included. The fact that the T lymphocytes with a CD56 are present in the liver and that same marker is also encountered on the Kuppfer cells, but not on the T lymphocytes in circulation, shows that in the liver the interleukin 6 is produced by the activated T lymphocytes and by the Kuppfer cells. Therefore, in such conditions, LB stimulation and growth is performed rather by IL-6 and to a lesser extent by IL-8. This statement is also supported by the finding that in the lymphocyte cultures in the peripheral blood there is no difference in the response to polyclonal mitogens between patients with CAH-HBAg(+) and those with CAH-HBAg(-). Also, there are no significant differences in the total immunoglobulin concentrations, but there are differences in the IgM concentration (greater in CAH-HBAg(+). In our investigations, the serum level of IL-6 (40.1 +/- 6.8 pg/ml) was higher in those with higher immunoglobulin concentrations-both IgG, but more particularly IgM. The IgM increase was correlated with the presence of HBAg. Therefore, the highest IL-6 values were found in CAH with HBAg(+). Increases of serum IL-6 concentrations were found during intervals of severe hepatic aggression manifested in a cytolitic syndrome, with transaminase increase. In the case of determinations in dynamics, the values decreased as the enzyme titre decreased. We can state that the serum activity of IL-6 reflects the degree of liver inflammation and can be used as a parameter for monitoring the disease.

[The effect of atmospheric temperatures on eye diseases in the Cluj area]

The influence of the temperature of the air on the following ocular disease: acute glaucoma, uveitis and herpes keratitis, is studied in this paper through the X2 statistical method. Concerning the meteorological factor we studied five characteristics: medium temperature of the day, maximum temperature of the day, minimum temperature difference between maximum and minimum temperature of the day, difference of the temperature between the day before and the day when disease occurred. Concerning the ocular disease we studied the date of the first symptoms. The study has two distinct parts: a) study of the comparative action of seasons inside of a well definite step of temperature; b) study of the influence of the temperature inside of each season.

[The effect of meteorological factors on the body in general and on the eye in particular]

Some data of the literature concerning the action of the weather factors on the human body are presented. In the same time the knowledge about the modifications induced in the healthy organism by the atmospheric factors and the biotropical action of the weather factors and about some ocular diseases, whose evolutions in made worse by the weather factors, is summarized.

[Penetrating orbital wounds with retention of the plant foreign bodies]

Here are presented the clinical observations of 5 patients with these diagnosis. We discussed the necessity of attentive exploration of the orbital injuries in the moment of urgency interventions because the foreign bodies can be multiplied. It is also important to suspect the retention of wood foreign bodies in the orbit in the presence of the patients: orbital fistula with an orbital injury in their antecedents.