Cryptogenic stroke: time to determine aetiology

Strokes that remain without a definite cause even after extensive work-up are classified as cryptogenic. These constitute about 30-40% of all strokes. Stroke aetiology may remain undetermined for the following reasons: (i) the cause of stroke is transitory or reversible and the diagnostic work-out is not therefore performed at the appropriate time; (ii) all known causes of stroke are not fully investigated; (iii) some causes of stroke remain unknown. Recent studies have challenged the previous view that cryptogenic stroke is a relatively benign cerebrovascular event, and have shown that cryptogenic stroke is associated with a higher rate of recurrence and adverse outcome at long-term follow-up. The determination of stroke aetiology is a valuable procedure to avoid the risk of stroke recurrence, especially in young patients. In this review, we discuss new evidence on the aetiology of cryptogenic stroke, specifically focusing on patients with patent foramen ovale and atheroma of the aortic arch.

Botulinum-A toxin: an exciting new treatment option for prostatic disease

Recently, botulinum neurotoxin type A (BoNT-A) application in the lower urinary tract has been extended to prostate disorders and we would like to review the literature on the mechanisms of action and clinical efficacy of BoNT-A treatment in the prostate. The information was gathered from MEDLINE, abstracts from recent urological meetings and from personal experience. BoNT has demonstrated promising preliminary results for male prostatic disease and translational research suggests a novel mechanism of action of BoNT in the prostate. It is important to remember that the application of BoNT in the prostate is not approved by the regulatory agencies and caution should be applied until larger randomised clinical studies are completed.

Influenza vaccination in patients on long-term anticoagulant therapy

The study evaluates the risk/benefit of influenza vaccination in patients on stable long-term oral anticoagulant therapy (OAT). One hundred and four consecutive patients with indication for influenza vaccination were randomized to receive one dose of 2004/2005 influenza vaccine followed by placebo after 6 weeks, or vice versa, in a cross-over blinded trial. All patients were tested for anticoagulation levels and for hemagglutination inhibiting antibody titres against the influenza vaccine antigens. The highly protective antibody titres induced by influenza vaccination and the absence of statistically relevant interactions between vaccination and OAT suggest that influenza vaccination can be used safely and successfully in elderly patients on OAT.

Safety and Efficacy of Ximelagatran: Meta-Analysis of the Controlled Randomized Trials for the Prophylaxis or Treatment of Venous Thromboembolism

BACKGROUND

Ximelagatran has been approved in Europe for VTE prophylaxis in orthopedic surgery at fixed doses and without laboratory monitoring. Aim of the study was to evaluate safety and efficacy of ximelagatran in a meta-analysis of prophylaxis and/or treatment randomized controlled trials.

METHODS

Absolute risk of events for ximelagatran and OR for its comparison with LMWH and coumarins were calculated. Subgroup analysis was performed for ximelagatran regimen, comparator agent, type of surgery, starting time of prophylaxis.

RESULTS

Twelve studies and 16,992 patients were meta-analysed. Ximelagatran showed an absolute risk of major VTE of 4.04% and 1.69% and of major bleedings of 1.68% and 1.03% in prophylaxis and treatment trials, respectively. In prophylaxis trials, a significant excess mortality (OR: 2.5; 95% CI: 1.02 - 6.13) and an excess in major bleedings (OR: 1.41; 95% CI: 0.93 - 2.14) was found in the whole ximelagatran group. No evidence of treatment effect for major VTE was seen in the comparison with LMWH (OR: 1.01; 95% CI: 0.52 - 1.97). The cohort of patients treated with 24 mg b.i.d. showed similar results. An increase in the absolute risk of bleeding (from 1.04% to 3.03%) was found between post and preoperative administration of ximelagatran. Major VTE risk was increased when ximelagatran was compared to b.i.d. LMWH.

CONCLUSIONS

Ximelagatran can be considered for its potential advantages for prevention and treatment of VTE. Future efforts are needed by researchers to prospectively investigate the best postoperatively starting time and by clinicians to monitor overall mortality in prophylactic use.

Prophylaxis in Female Urinary Infections in Women

Recurrent urinary tract infections (UTI) in women cost billions of euro annually. E. Coli causes 70–95% of these infections and it has been observed, in vitro and in vivo, to have the capability to develop bacterial biofilms in the bladder: polysaccharide-rich matrix. At the present, the only way to overcome this mucopolysaccaride barrier is to administer long repeated cycles of chemotherapy. We submit prophylaxis to patients with recurrent UTI to sterilize urine for at least 6 consecutive months.

Materials and Methods

42 women with recurrent UTI have been selected according to: urine culture, vaginal swabs, and DNA-probe for Chlamydia, Gonococcus, Mycoplasma. After giving informed consent patients were assigned to treatment group A and B. For the first 10 days both groups received ciprofloxacin 500 mg bid, and then group A received ciprofloxacin 250 mg on alternate days and 1 cpr before every sexual intercourse. The group B received placebo in the same modality. Every sexual intercourse had to be safe. All the patients, after the initial screening, repeated an urine culture every 10 days for the first 6 months and every 20 days for the next 6 months. The statistical analysis was performed by chi-square test.

Results

44 patients finished the study. 23 pt of group A had sterile urine for the first 6 months of the study and 81% for the next 6 months; 1/23 had 2 episodes of symptomatic UTI. 71% of the 21 patients of group B had symptomatic bacteriuria 20 days after the first treatment (p<0.001). 16/21 patients had symptomatic UTI in the first 6 months of the study and the 90% in the 12 months of the study (p<0.001), in spite of every poussèe was treated with the same antibiotic scheme.

Conclusions

This kind of prophylaxis has few collateral effects, and it appears to be effective in the treatment of recurrent UTI in women.

Low-molecular-weight heparin for the long-term treatment of symptomatic venous thromboembolism: meta-analysis of the randomized comparisons with oral anticoagulants

BACKGROUND

The management of venous thromboembolism (VTE) requires an initial treatment with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH), followed by oral anticoagulants (OA) for at least 3 months. OA treatment however, requires laboratory monitoring of anticoagulation, carries a definite risk of bleeding, and may be contraindicated in some patients. As an alternative to vitamin K antagonists, subcutaneous LMWH has been proposed and evaluated in randomized clinical trials, but they are all small studies that lack the power to establish if these two treatment modalities are equivalent in efficacy or safety.

OBJECTIVES

The objective of this review was to evaluate the efficacy (VTE recurrence) and safety (bleeds and deaths) of long-term treatment of VTE with LMWH compared with OA. A secondary endpoint was to evaluate the effect of LMWH on cancer mortality.

METHODS

Computerized searches of MedLine and EmBase were performed. In addition, randomized clinical trials were located through personal communication with colleagues, and through the manual scanning of meeting proceedings and reference lists of relevant studies. When necessary, the authors of the selected papers were called to obtain additional information. Two reviewers (AI and FG) reviewed and extracted data independently using a standard form. The primary analysis was performed for efficacy and safety endpoints on an intention-to-treat basis for the study period of randomized treatment. A meta-regression analysis was used to investigate the relationship between daily dose and clinical outcome.

RESULTS

Seven studies that fulfillled our predefined criteria were identified, for a total of 1379 patients. When all studies were combined, a statistically non-significant reduction in the risk of VTE (OR 0.66; 95% confidence interval [CI] 0.41, 1.07) and in the risk of major bleeding (OR 0.45; 95% CI 0.18, 1.11) in favor of LMWH treatment was found. No difference in total mortality (OR 1.19; 95% CI 0.78, 1.83) or in cancer-related mortality was observed between the LMWH and the OA treatment.

CONCLUSIONS

The results of this meta-analysis indicate that a 3-month course of LMWH is as effective and safe as a corresponding period of OA treatment, and may thus be considered as a valuable alternative option for patients in whom OA treatment appears contraindicated or problematic.

Intrinsic sphincter deficiency: do the maximum urethral closure pressure and the Valsalva leak-point pressure identify different pathogenic mechanisms?

A prospective analysis of 166 women with genuine stress incontinence was performed comparing Valsalva leak-point pressure (VLPP) and maximum urethral closure pressure (MUCP) with age, previous urogynecologic surgery and/or hysterectomy, poor urethral mobility, weight, menopause and vaginal deliveries, to find correlations with intrinsic sphincter deficiency (ISD). Cut-off value for VLPP were 60 cmH2O and for MUCP 30 cmH2O. MUCP < or = 30 cmH2O identifies a group of patients with more severe incontinence, a shorter urethral functional length (UFL) (P = 0.02), more previous urogynecologic operations and the menopause (P = 0.004 and P = 0.000), and older age (P = 0.000). VLPP < or = 60 cmH2O identifies a group of patients with more severe incontinence, a shorter UFL (P = 0.005), more previous urogynecologic surgery (P=0.006) and poorer urethral mobility (P = 0.004). As these two tests measure different components of urethral functions we can hypothesize that they detect different pathogenic processes contributing to ISD. When one or both tests is abnormal incontinence is more severe and the incidence of poor prognostic factors is increased.

[Uro-gynecologic protocol for studying urinary stress incontinence]

Regarding the difficulty in using a common and standardised language in the diagnosis of Stress Urinary Incontinence (SUI) the authors developed a research protocol based on anamnestic, clinical, urodynamic and imaging forms, in order to have a numerous elements for the evaluation of this pathology. The preliminary study had to identify the most meaningful and common parameters, encoded according to broadly approved literature or the classification proposed by International Continence Society (ICS). One of the fundamental purposes was to clarify the role of ultrasonography technique applied to the field of Stress Incontinence. In this article the authors explain the choices they make, the technique employed for such a study and the ultrasonic images that are pathognomonic of the specific anatomo-functional disorders.

[Echographic study of the bladder neck and prostate region after Nd-Yag laser treatment]

The authors describe the ultrasonic images they obtained in the follow up of three groups of patients who were divided according to basic pathology and treated with Nd: Yag Laser with contact (CLAP) and side firing (VLAP) fibers. Next the great differences noted between the results achieved with ultrasonic investigation and those obtained with flowmeter controls and IPSS are presented. The authors discuss the possible causes of these dissonances and hypothesize a new way to evaluate cervico-urethral de-obstruction: no longer an anatomical technique but a functional one.

[Echo-guided drainage of pararenal and pelvic fluid accumulations: technique, indications, and results]

Percutaneous echoguided drainage of retroperitoneal collections is to be considered a recommendable technique which guarantees a good percentage of success and a complete resolution of the effusions and also gives a low percentage of complications. The drainage can be made through a simple percutaneous needle puncture or through a catheter which is kept for some days. The latter technique done by Seldinger or Trocar's method, guarantees more possibilities of success. The systemic echographic control during the post-operatory period of the urological patients have permit to find out the high frequency of small fluid effusions (haematic, urinary or lymphatic) in the operation area; not all the collections need a treatment. The urinary collections or those with clinical signs of anemia have to be drained. In the presence of small haematic or lymphatic collections, the ultrasonography follow-up shows almost always a progressive volume reduction with a following disappearance. Percutaneous drainage has to be performed in the presence of a large collection (more than 5 cm of diameter), in the case of a persistent collection or when patient presents with clinical features of infection.

[Color Doppler echography of the cavernous bodies after F.I.C. in the study of erectile impotence of vascular origin]

Study with the Doppler method has been associated with "cavernometrics" and "cavernography" in erection pathologies for some time. But this enquiry is burdened not only be technical inaccuracies such as the lack of knowledge of the angle of incidence of the doppler wave and the diameter of the explored vessel etc, but also by intrinsic difficulty method itself. Therefore, the authors have used a color Doppler to individuate and study the cavernous arteries, and present the results obtained from a group of 21 patients, all affected by erectile deficits, who were selected on the basis of anamnestica and clinical criteria. They individualized 21 patients in whom the vasculogenic nature of their affection appeared probable, out of the 125 who were under their observation for their sexual inadequacy. In three patients the clinical suspicion of a venous incompetency was confirmed by dynamic "cavernometrics with cavernography". The study of the four phases of erection (flaccidity, tumescence, erection, detumescence) was carried out after an intracavernous injection of 20 micrograms of PGE/1. The parameters considered were: systolic velocity of the hematic wave, diastolic speed, the index of resistance and range. In cases of vasculogenic impotence with an arterial base the systolic wave in the 2nd and 3rd phases presented a speed inferior to the norm of standard values, the resistance index altered by the lacking of physiological increment due in the erectile beyond the closing of venous "polsters", also to the rigidity of the albuginea.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echographic evaluation of the undescended testis beyond the therapeutically useful period. Echopattern and testicular volume]

Echotomography and C.T. scan are the most common Imaging Techniques to study undescended testis: the echotomography for the inguinal, crural, perineal and penile localization; C.T. scan for the abdominal localization. The aim of this study was to evaluate morphological and volumetric alterations of testis in pre- and post-puberal patients with echotomography and C.T. scan. 65 patients were divided in two groups on the basis of age: group 1 (5-13 yrs; n = 46) and group 2 (> 13 yrs; n = 19). The volumetric and echo-structural alterations were more frequent in group 2 than in group 1. In group 1 a significant difference was observed between the incidence of echo-structural (35%) and volumetric (65%) alterations. A retained testis shows increased morphological alterations by aging. On the basis of these results we can conclude that in the group 1 the volumetric analysis is more reliable than the echo-structural analysis to evaluate testis "well-state".

[A case of congenital renal malformation with arteriovenous fistula]

Renal arteriovenous fistulas caused by vascular malformation are relatively rare, with a reported prevalence of less than 0.04%. The authors discuss about a clinical case studied by Echo-color-doppler, C.T. scan and Digital angiography. Nevertheless there is a good correlation between the results from these different Imaging Techniques, Duplex-Doppler seems to be poorly specific to define by itself a diagnosis of a tumoral renal mass.

[Color Doppler in the diagnosis of malignant prostatic neoplasia. Preliminary results]

In the field ultrasonic diagnosis the application of color code to the duplex Doppler signal is without doubt the most up-to-date method. The common knowledge according to which all heteroplastic structures need a large quantity of O2 and provoke the formation of new vessels with the angiogenesis factor, with particularly rapid, and tumultuous fluxes due to the presence of shunt, is the basis for the use of color doppler in research on neoplasia in the initial phase. The authors submitted 11 patients considered at risk, to an echocolor Doppler study of the prostate, with a transrectal biplane probe of MHz. The exclusive application of ultrasonography grey scale, permitted the diagnosis of malignant neoplasia in 5 of these subjects. The following "color" exploration led to a cancer diagnosis in 10 patients. A bioptic check carried out through transperineal way color guided allowed the diagnosis of 8 'adenocarcinomas' and 1 undifferentiated CA.