[Analysis of management efficacy in patients with heavy menstrual bleeding associated with antithrombotic therapy]

Objective: To evaluate different methods' efficacy of controlling acute bleeding and managing long-term menstruation in patients with heavy menstrual bleeding (HMB) associated with antithrombotic therapy. Methods: The clinical data of 22 cases with HMB associated with antithrombotic therapy admitted to Peking University People's Hospital from January 2010 to August 2022 were analyzed, aged 39 years old (26-46 years). Changes in menstrual volume, hemoglobin (Hb), and quality of life were collected after control of acute bleeding and long-term menstrual management. Menstrual volume was assessed by pictorial blood assessment chart (PBAC), and quality of life was assessed by menorrhagia multi-attribute scale (MMAS). Results: (1) Treatment of acute bleeding: of the 22 cases with HMB associated with antithrombotic therapy, 16 cases were treated in our hospital and 6 in other hospital for emergency bleeding; of the 16 cases treated in our hospital, 3 underwent emergency intrauterine Foley catheter balloon compression due to severe bleeding (Hb decreased by 20 to 40 g/L within 12 hours). Of the 22 cases with antithrombotic therapy-related HMB, 15 (including 2 cases with severe bleeding) underwent emergency aspiration or endometrial resection, and intraoperative placement of levonorgestrel-releasing intrauterine system (LNG-IUS) followed by a significant reduction in bleeding volume; 3 cases had controlled acute bleeding after rivaroxaban dose reduction and continued observation; 2 cases were given gonadotropin-releasing hormone agonists to control acute bleeding in other hospital, of which 1 case was temporarily treated with periodic blood transfusion, and the other one patient underwent total hysterectomy; and 2 cases had temporary amenorrhea with oral mifepristone after intrauterine balloon compression or oral norethindrone. (2) Long-term menstrual management: of the 22 cases with antithrombotic therapy-related HMB, 15 had LNG-IUS placement and 12 had LNG-IUS placement for 6 months, and menstrual volume was significantly reduced [PBAC scores were 365.0 (272.5-460.0) vs 25.0 (12.5-37.5), respectively; Z=4.593, P<0.001], Hb was significantly increased [91.5 g/L (71.8-108.2 g/L) vs 128.5 g/L (121.2-142.5 g/L); Z=4.695, P<0.001], and quality of life was significantly improved [MMAS scores were 415.0 (327.5-472.5) vs 580.0 (570.0-580.0), respectively; Z=-3.062, P=0.002] before placement compared with 6 months after placement. Three rivaroxaban dose reduction patients' PBAC scores decreased by 20 to 35 but remained >100, and perceived quality of life did not change significantly. Two cases with temporary amenorrhea treated with oral mifepristone felt significantly improved quality of life, and the MMAS scores increased by 220 and 180, respectively. Conclusion: Intrauterine Foley catheter balloon compression, aspiration or endometrial ablation could be used to control acute bleeding in patients with antithrombotic therapy-related HMB, and LNG-IUS for long-term management could reduce menstrual volume, increase hemoglobin, and improve the quality of life of patients.

[Analysis of pathogen spectrum and antimicrobial resistance of pathogens associated with hospital-acquired infections collected from 11 teaching hospitals in 2018]

Objective: To investigate the spectrum and antimicrobial resistance of major pathogens causing nosocomial infections in China, 2018. Methods: Non-duplicated nosocomial cases as well as pathogens causing bloodstream infections (BSI), hospital-acquired pneumonia (HAP) and intra-abdominal infections (IAI) from 11 teaching hospitals across China were collected. The minimum inhibitory concentrations (MICs) of clinically significant strains were determined by agar dilution method or broth microdilution method. The Clinical and Laboratory Standards Institute (CLSI) M100-S29 criteria were used for interpretation, and the WHONET-5.6 software was used in data analysis. Results: A total of 1 590 cases were collected, including 831 cases from BSI, 450 cases from HAP and 309 cases from IAI. The most prevalent pathogens causing BSI were Escherichia coli (29.2%, 243/831), Klebsiella pneumoniae (16.2%, 135/831) and Staphylococcus aureus (10.1%, 84/831); the most prevalent pathogens causing IAI were E. coli (26.2%, 81/309), Enterococcus faecium (15.5%, 48/309) and K. pneumoniae (13.3%, 41/309); while Acinetobacter baumanii (24.7%, 111/450), Pseudomonas aeruginosa (20.7%, 93/450) and K. pneumoniae (16.2%, 73/450) were dominated in HAP. All S. aureus were susceptible to tigecycline, linezolid, daptomycin and glycopeptides; 77.8% (105/135) of S. aureus strains were susceptible to ceftaroline. Methicillin-resistant S. aureus (MRSA) accounted for 29.6% (40/135) of all the S. aureus, and was lower than the accounted rate of methicillin-resistant coagulase-negative Staphylococcus (MRCNS) (83.7%, 41/49). One E. faecium strain (1.1%, 1/95) resistant to vacomycin and teicoplanin and one E. faecalis strain (2.3%, 1/43) resistant to linezolid was found. The prevalence of extended-spectrum β-lactamase (ESBL) was 56.1% (193/344) in E. coli and 22.1% (55/249) in K. pneumonia; the rate of carbapenem resistant E. coli and K. pneumonia was 4.1% (14/344) and 22.9% (57/249), respectively; the percentage of ceftazidime/avibactam resistant E. coli and K. pneumonia was 2.3% (8/344) and 2.0% (5/249), respectively; the percentage of colistin resistant E. coli and K. pneumonia was 1.5% (5/344) and 7.6% (19/249), respectively; no E. coli and K. pneumonia strains were found resistant to tigecycline. The rate of carbapenem resistant A. baumanii and P. aeruginosa were 78.9% (146/185) and 36.7% (66/180), respectively. A. baumanii showed low susceptibility to the antimicrobial agents except colistin (99.5%, 184/185) and tigecycline (91.4%, 169/185). Colistin, amikacin and ceftazidime/avibactam demonstrated high antibacterial activity against P. aeruginosa with susceptility rate of 100% (180/180), 93.3% (168/180) and 85.6% (154/180), respectively. Conclusions: Nosocomial Gram-negative pathogens show high susceptibilities to tigecycline, colistin and ceftazidime/avibactam in vitro. Antimicrobial resistance in A. baumannii is a serious problem. The prevalence of carbapenem-resistant Enterobacteriaceae has increased, which should be monitored continuously in China.

Argon Laser Peripheral Iridoplasty for Primary Angle-Closure Glaucoma: A Randomized Controlled Trial

PURPOSE

To determine the effectiveness of argon laser peripheral iridoplasty (ALPI) in primary angle closure (PAC) and primary angle-closure glaucoma (PACG).

DESIGN

Randomized controlled trial.

PARTICIPANTS

Eighty PAC or PACG subjects who underwent laser iridotomy (LI) and had at least 180° of persistent appositional angle closure and intraocular pressure (IOP) of more than 21 mmHg were enrolled.

METHODS

Subjects were randomized to receive either 360° ALPI (Visulas 532s; Carl Zeiss Meditec, Jena, Germany) or medical therapy (Travoprost 0.004%; Alcon-Couvreur, Puurs, Antwerp, Belgium). Repeat ALPI was performed if the IOP reduction was less than 20% from baseline along with inadequate angle widening at the month 1 or month 3 visit. Intraocular pressure was controlled with systematic addition of medications when required.

MAIN OUTCOME MEASURES

The primary outcome measure was success rates after ALPI at 1 year. Complete success was defined as an IOP of 21 mmHg or less without medication, and qualified success was defined as an IOP of 21 mmHg or less with medication. Failure was defined as an IOP more than 21 mmHg despite additional medications or requiring glaucoma surgery.

RESULTS

Forty subjects (51 eyes) were randomized to ALPI and 40 subjects (55 eyes) were randomized to medical therapy. Complete success (IOP ≤21 mmHg without medication) was achieved in 35.0% eyes of the ALPI group compared with 85.0% of eyes in the prostaglandin analog (PGA) group (P < 0.001), and qualified success (IOP ≤21 mmHg with medication) was achieved in 35.0% and 7.5%, respectively (P = 0.003). The IOP decreased by 4.9 mmHg (95% confidence interval [CI], 3.5-6.3 mmHg) in the ALPI group (P < 0.001) and by 6.1 mmHg (95% CI, 5.1-7.1 mmHg) in the medication group (P < 0.001). A failure rate of 30.0% was noted in the ALPI group compared with 7.5% in the medication group (P = 0.01). No treatment-related complications were recorded in either group.

CONCLUSIONS

After 1 year, ALPI was associated with higher failure rates and lower IOP reduction compared with PGA therapy in eyes with persistent appositional angle closure and raised IOP after LI.

A common variant near TGFBR3 is associated with primary open angle glaucoma

Primary open angle glaucoma (POAG), a major cause of blindness worldwide, is a complex disease with a significant genetic contribution. We performed Exome Array (Illumina) analysis on 3504 POAG cases and 9746 controls with replication of the most significant findings in 9173 POAG cases and 26 780 controls across 18 collections of Asian, African and European descent. Apart from confirming strong evidence of association at CDKN2B-AS1 (rs2157719 [G], odds ratio [OR] = 0.71, P = 2.81 × 10⁻³³), we observed one SNP showing significant association to POAG (CDC7–TGFBR3 rs1192415, OR_G-allele = 1.13, P_meta = 1.60 × 10⁻⁸). This particular SNP has previously been shown to be strongly associated with optic disc area and vertical cup-to-disc ratio, which are regarded as glaucoma-related quantitative traits. Our study now extends this by directly implicating it in POAG disease pathogenesis.

Efficacy of selective laser trabeculoplasty in primary angle-closure glaucoma: a randomized clinical trial

IMPORTANCE

Selective laser trabeculoplasty (SLT) should be explored as a therapeutic option in eyes with angle closure.

OBJECTIVE

To assess the intraocular pressure (IOP)-lowering efficacy of SLT in eyes with primary angle closure (PAC) and PAC glaucoma (PACG).

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial at tertiary eye care institutions of 100 patients diagnosed as having PAC or PAC glaucoma in which the angles had opened at least 180° (visible posterior trabecular meshwork on gonioscopy) after laser iridotomy. Recruitment and baseline were completed from June 2009 to April 2012 and 6-month follow-up was completed from December 2009 to November 2012.

INTERVENTIONS

Eligible patients with a baseline IOP greater than 21 mm Hg were randomized to either SLT or prostaglandin analog (PGA; travoprost, 0.004%). The SLT was repeated if the IOP reduction was less than 20.0% from baseline at the 1- or 3-month follow-up visit.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was the change in IOP from baseline to the final follow-up visit (at 6 months). The frequency of additional postoperative treatments and complications were secondary outcomes.

RESULTS

Fifty patients (96 eyes) were randomized to SLT and 50 patients (99 eyes) to PGA medical therapy. At 6 months, 49 patients in the SLT group and 47 in the PGA group completed follow-up. Analysis was based on intent to treat. At 6 months, IOP decreased by 4.0 mm Hg (95% CI, 3.2-4.8) in the SLT group (P < .001) and by 4.2 mm Hg (95% CI, 3.5-4.9) in the PGA group (P < .001). There were no differences between the SLT and PGA groups in the absolute mean reduction of IOP (4.0 vs 4.2 mm Hg, respectively; P = .78) or in the percentage of reduction in IOP (16.9% vs 18.5%, respectively; P = .52). Complete success (IOP ≤21 mm Hg without medications) was achieved in 60.0% eyes of the SLT group, compared with 84.0% of eyes in the PGA group (P = .008). No patients required glaucoma surgery. Additional medications were required in 22.0% of patients in the SLT group compared with 8.0% in the PGA group (P = .05). One patient in the SLT group (2.0%) had a transient posttreatment IOP spike greater than 5 mm Hg. The mean endothelial cell count showed a significant decrease from baseline in the SLT arm (4.8% decrease; P = .001). No other events such as persistent uveitis or increase in peripheral anterior synechiae were noted in eyes that underwent SLT. Two patients in the PGA group exited owing to drug-related complications (1 patient with uveitis and 1 with allergic conjunctivitis).

CONCLUSIONS AND RELEVANCE

Eyes with PAC or PACG respond to SLT in the short term, but the overall long-term therapeutic effectiveness needs further evaluation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01004900.

Angle-closure glaucoma in Asians: comparison of biometric and anterior segment parameters between Japanese and Chinese subjects

PURPOSE

To compare anterior segment parameters in Chinese and Japanese subjects with angle closure using anterior segment optical coherence tomography (ASOCT).

METHODS

One hundred and forty-two Japanese and one hundred and ninety-two Chinese subjects with primary angle closure (PAC) or primary angle-closure glaucoma (PACG) were recruited. All participants underwent A-scan biometry and ASOCT imaging (Visante, Carl Zeiss Meditec, Dublin, CA, USA). Customized software was used to measure ASOCT parameters in horizontal ASOCT scans. The parameters were compared, and multivariate analysis was performed to determine predictors of angle opening distance at 750 μm from the scleral spur (AOD750).

RESULTS

Ethnic difference evaluated by multiple linear regression adjusted for age, gender, spherical equivalent, pupil diameter, and axial length showed that Japanese angle-closure subjects had significantly shallower anterior chamber depth (ACD;β = -0.3, p < 0.001), smaller anterior chamber area (ACA; β = -0.21, p = 0.02) and volume (ACV; β = -0.19, p = 0.01), greater lens vault (LV, β = 0.3, p < 0.001), lens thickness (LT; β = 0.48, p < 0.001), greater iris area (IArea; β = 0.19, p = 0.01), and more curved iris (ICurv; β = 0.16, p = 0.04). The significant determinants of AOD750 were iris thickness (IT; β = -0.21, p = 0.04), ICurv (β = -0.17, p = 0.04), pupil diameter (PD; β = -0.34, p = 0.001) and ACV (β = 0.32, p < 0.001) in Japanese; and IT (β = -0.25, p = 0.001), ACV (β = 0.37, p < 0.001), PD (β = -0.26, p = 0.001), and LV (β = -0.18, p = 0.03) in Chinese.

CONCLUSIONS

Compared to Chinese, Japanese angle-closure eyes have smaller and more crowded anterior segment with thicker lenses. ACV, IT, and PD are important factors for angle width in both races. These results suggest possible ethnic differences in angle-closure mechanism(s).

Central corneal thickness in Chinese subjects with primary angle closure glaucoma

PURPOSE

To characterize central corneal thickness (CCT) in Chinese eyes with primary angle closure glaucoma (PACG).

METHODS

CCT was measured by ultrasound pachymetry in PACG eyes and compared with primary open-angle glaucoma (POAG) eyes. POAG eyes were further subdivided into high-tension glaucoma (HTG) and normal-tension glaucoma (NTG) for analysis. PACG eyes had glaucomatous optic neuropathy and visual field loss, an angle in which at least 180 degrees of angle in which the posterior trabecular meshwork was not visible, and raised intraocular pressure (IOP) and/or peripheral anterior synechiae. Both HTG (IOP >21 mm Hg) and NTG (IOP consistently <21 mm Hg) eyes had glaucomatous optic neuropathy with compatible visual field defects and open angles. Further comparison was made with CCT data of 1067 normal subjects previously enrolled in a population-based study.

RESULTS

We enrolled 154 patients with PACG and 300 with POAG. Mean age of PACG patients was 68.1±8.3 years compared with 71.1±12.4 years in POAG patients (P=0.002). There was no difference in mean CCT of PACG eyes (541.28±33.95 μm) and POAG eyes (539.28±34.84 μm, P=0.56) or normal eyes of control subjects (536.74±31.08 μm) (P=0.07). However, mean CCT of NTG eyes (535.23±36.10 μm) was significantly lower than that of HTG eyes (543.44±33.10 μm, P=0.04), and HTG eyes had thicker CCT than normal eyes (P=0.01).

CONCLUSIONS

PACG eyes had similar CCT as those with POAG or normal eyes in Chinese subjects.

Comparison of ocular response analyzer parameters in chinese subjects with primary angle-closure and primary open-angle glaucoma

OBJECTIVES

To evaluate corneal hysteresis (CH) and intraocular pressure (IOP) measured by the Ocular Response Analyzer in Chinese subjects with primary angle-closure glaucoma (PACG), assess their relationship with Goldmann applanation tonometry (GAT) measurements, and compare this with subjects with primary open-angle glaucoma (POAG) and normal controls.

METHODS

In this prospective observational study, consecutive subjects with PACG and POAG without prior intraocular surgery were enrolled from glaucoma clinics. Normal subjects were recruited from an ongoing population-based study. One eye of each subject underwent standardized ocular examination and IOP measurement by GAT and the Ocular Response Analyzer. Corneal hysteresis and corneal-compensated IOP were compared between groups.

RESULTS

Of the 443 subjects recruited, 131 had PACG, 162 had POAG, and 150 were normal. Corneal hysteresis was lower in PACG (9.1 mm Hg; 95% confidence interval [CI], 8.7 to 9.4 mm Hg) and POAG (9.5 mm Hg; 95% CI, 9.2 to 9.5 mm Hg) eyes compared with control eyes (10.4 mm Hg; 95% CI, 10.1 to 10.6 mm Hg; P < .001 for both), with no difference (P = .16) in CH found between PACG and POAG eyes. After adjusting for age, sex, and IOP measurement by GAT, CH persisted to be lower only in eyes with PACG in comparison with control eyes (9.4 vs 10.1 mm Hg; P = .006). Eyes with POAG had lower CH than control eyes but the difference was not statistically significant (9.6 vs 10.1 mm Hg; P = .06).

CONCLUSIONS

Corneal hysteresis was lower in eyes with glaucoma. After adjusting for age, sex, and IOP measurement by GAT, a persistently lower hysteresis was noted in eyes with PACG compared with other groups.

Virulence and potential pathogenicity of coccoid Helicobacter pylori induced by antibiotics

AIM: To explore the virulence and the potential pathogenicity of coccoid Helicobacter pylori (H. pylori) transformed from spiral form by exposure to antibiotic.

METHODS: Three strains of H. pylori, isolated from gastric biopsy specimens of confirmed peptic ulcer, were converted from spiral into coccoid from by exposure to metronidazole. Both spiral and coccoid form of H. pylori were tested for the urease activity, the adherence to Hep 2 cells and the vacuolating cytotoxicity to Hela cells, and the differences of the protein were analysed by SDS-PAGE and Western blot. The mutation of the genes including ureA, ureB, hpaA, vacA and cagA, related with virulence, was detected by means of PCR and PCR-SSCP.

RESULTS: In the coccoid H. pylori, the urease activity, the adherence to Hep 2 cells and the vacuolating cytotoxicity to Hela cells alldecreased. In strain F₄₄, the rate and index of adherence reduced from 70.0% ± 5.3% to 33% ± 5.1% and from 2.6 ± 0.4 to 0.96 ± 0.3 (P < 0. 01), respectively. The invasion of coccoid H. pylori into Hep 2 cell could be seen under electronmicroscope. SDS-PAGE showed that the content of the protein with the molecular weight over Mr 74000 decreased, and the hybriditional signal in band Mr 125000 weakened, while the band M_r 110000 and Mr 63000 strengthened in coccoid H.pylori as shown in Western blot. The results of PCR were all positive, and PCR-SSCP indicated that there may exist the point mutation in gene hpaA or vacA.

CONCLUSION: The virulence and the proteins with molecular weight over Mr 74000 in coccoid H.pylori decrease, but no deletion exists in amplification fragments from ureA, ureB, hpaA, vacA and cagA genes, suggesting that coccoid H.pylori may have potential pathogenicity.

Diabetic retinopathy and serum lipids

The association between serum lipid levels and diabetic retinopathy has been investigated in many studies. Some studies show a positive relationship between serum cholesterol and low-density lipoprotein levels and retinal hard exudation. Other studies show serum triglyceride levels as being important in the progression of retinopathy. Certain other studies show no relationship between serum lipid levels and diabetic retinopathy. We review the literature on this subject and illustrate this report with an example of a diabetic with severe diabetic maculopathy and high serum lipid levels.

Results of revision total knee arthroplasty

BACKGROUND/AIM OF STUDY

The results of primary total knee arthroplasties have improved over the years but some still fail, requiring revision. Revision total knee arthroplasty is technically more difficult and has not enjoyed the same success rates as the index operation. The aim of this retrospective study was to review the results of revision total knee arthroplasties carried out at our centre. This is the first study in Singapore on revision total knee arthroplasty.

METHODS

A retrospective study where 17 patients (18 knees) had been followed up since their revision operations were clinically assessed. Based on the Knee Society Clinical Scoring System, they were assigned separate knee and function scores (each having a maximum possible 100).

RESULTS

The mean knee score was 76 (range 35-93), which rates as good. Of the 18 knees, 67% had excellent or good knee scores. By comparison, the mean function score was 56 (range 0-90) which rates as poor and 33% had excellent or good function scores.

CONCLUSION

Revision total knee arthroplasty achieves good and excellent results in spite of technical difficulties often associated with the revision operation. The difference in mean knee and function scores emphasises that many other factors such as physical strength and stamina affect function. Nevertheless, 15 patients were able to walk out of their house and around their neighbourhood for varying distances. This satisfied their expectations and the poor mean function score may reflect different expectations of patients overseas from whence this scoring system originated.

Screening for hypercholesterolaemia in patients with other risk factors for coronary heart disease

OBJECTIVE

To determine the prevalence of hypercholesterolaemia in individuals with other major risk factors of coronary heart disease and markers of hypercholesterolaemia.

METHODS

A community-based cross-sectional study on a random sample of 261 persons aged between 35 and 69 years residing in the flatted housing estate of West Coast, Singapore, was conducted in 1997. A questionnaire, together with a medical examination and investigation involving the use of Reflotron machine, were used to collect the information required.

RESULTS

43.2% of the population had at least 1 major risk factor, with 18.1% being smokers, 18.1% with hypertension, 6.5% with diabetes mellitus, 5.1% being obese, and 5.0% with a family history of coronary heart disease. Higher percentages of individuals with hypercholesterolaemia were found when each risk factor was present. 9.5% had 2 or more risk factors, of which, 21.1% had high cholesterol levels. A high prevalence of hypercholesterolaemia that was statistically significant was found amongst subjects with corneal arcus below the age of 60.

CONCLUSIONS

The risk factors of coronary heart disease remain prevalent in our population. We recommend screening for serum cholesterol only in those with at least 2 major risk factors of coronary heart disease in the general population between 35 and 69 years of age.

Intestinal epithelia (T84) possess basolateral ligands for CD11b/CD18-mediated neutrophil adherence

The process of active intestinal inflammation can be modeled by the migration of neutrophils [polymorphonuclear leukocytes (PMN)] across monolayers of the human intestinal cell line T84. We now evaluate the polarity of early adhesive events occurring between human PMN and ligands on intact T84 monolayers. Transient Ca2+ depletion (tr-Ca-depl) of confluent monolayers grown on permeable supports (2 mM EDTA, 12 min, 37 degrees C) resulted in disruption of tight junctions separating apical and basolateral domains (resistance fell from 973 +/- 35 to 57.4 +/- 3.8 omega.cm2 after 12 min). The columnar T84 phenotype was not grossly altered by tr-Ca-depl. Access to basolateral membrane proteins from the apical surface after tr-Ca-depl was confirmed by enzyme-linked immunosorbant assay and immunofluorescence, using antibodies to the basolateral proteins E-Cadherin and beta 1-integrin. The effects of tr-Ca-depl on early events in PMN adhesion were next assessed. Neutrophils (2 x 10(6)) were applied to the apical surface of monolayers followed by stimulation with the chemotactic peptide N-formyl-methionyl-leucyl-phenylalanine (100 nM, 5 min, 37 degrees C) and quantitation. In comparison with control monolayers, tr-Ca-depl increased subsequent PMN adhesion (1.7 +/- 0.24 vs. 3.1 +/- 0.28 x 10(4) adherent PMN/monolayer; P < 0.005), which was inhibited 80% by anti-CD11b/CD18 antibodies. These experiments suggest that PMN adhere to subjunctional ligands on T84 cells in a CD11b/CD18-dependent fashion.