Cuff-assisted versus cap-assisted colonoscopy for adenoma detection: results of a randomized study

BACKGROUND

The adenoma detection rate (ADR) is the most important marker of colonoscopy quality. Devices to improve adenoma detection have been developed, such as the Endocuff and transparent cap. The aim of the current study was to examine whether there was a difference in ADR between Endocuff-assisted (EAC) and cap-assisted colonoscopy (CAC).

METHODS

A randomized prospective trial was conducted. Eligible patients included adults ≥ 18 years referred because of symptoms, surveillance, or colonoscopies as part of the Bowel Cancer Screening Programme (BCSP). The primary outcome measure was ADR. Secondary outcomes included mean number of adenomas, mean number of polyps, polyp detection rate, cecal intubation rate, and time to cecal intubation. Procedural measures, device removal rate, and adverse events were also recorded.

RESULTS

A total of 711 patients (51.1 % men; median age 63 years) were included, of whom 357 patients were randomized to EAC and 354 patients to CAC. In the intention-to-treat analysis, the ADR was similar in both groups: EAC 50.4 % (95 % confidence interval [CI] 45.1 - 55.7) vs. CAC 50.6 % (95 %CI 45.2 - 55.9). Similar results were obtained in the per-protocol analysis: EAC 51.6 % (95 %CI 46.2 - 57) vs. CAC 51.4 % (95 %CI 46 - 56.8). There were no differences between the two devices in ADR according to the mean number of adenomas and polyps per procedure, polyp detection rate, cecal intubation rate, and time to cecal intubation. Device removal rate and adverse events were also similar.

CONCLUSION

In this randomized study, no differences in ADR were found between Endocuff- and cap-assisted colonoscopy.

Accuracy for optical diagnosis of colorectal polyps in clinical practice

BACKGROUND

Optical diagnostic involves predicting polyp histopathology from its endoscopic characteristics. It is only recommended for diminutive polyps ( < or = 5 mm) and for predictions made with high confidence.

OBJECTIVES

To evaluate the accuracy of optical imaging in clinical practice and to assess if optical diagnosis is useful for predicting future colonoscopy surveillance intervals without waiting for histopathological analysis.

METHODS

consecutive > 18 years patients were enrolled in this prospective study. Colonoscopies were performed by five expert endoscopists who previously participated in an ex-vivo training. Colonoscopes CF-H180AL and CF-Q180AL were used together with Exera II (Olympus Medical System, Tokyo, Japan) processors. Each polyp was characterized in real time using white light and Narrow Band Imaging. Accuracy of optical diagnosis (S, E, NPV, PPV) and correlation between surveillance interval based on optical diagnosis and histopathological analysis were calculated.

RESULTS

311 colon polyps < 10 mm (216 diminutive) in 195 patients were analyzed. Accuracy of optical diagnostics for predictions made with high confidence: Diminutive polyps(sensitivity 0.59, specificity 0.92, NPV 0.48); polyps < 10 mm (sensitivity 0.73, specificity 0.88, NPV 0.50). An optical diagnosis based surveillance recommendation was given to 90 patients. Concordance with histopathology based recommendation was 92.2% according to the European guideline and 93.3% according to the ESGE guideline.

CONCLUSIONS

Optical diagnostics can be used to predict future surveillance intervals immediately after colonoscopy. However, in this study, based on clinical practice, the accuracy of optical imaging is below the recommended standards.

Factors related to the effectiveness of variable stiffness colonoscope: results of a multivariate analysis

BACKGROUND

Various studies and two meta-analysis have shown that a variable stiffness colonoscope improves cecal intubation rate. However, there are few studies on how this colonoscope should be used.

OBJECTIVE

The aim of this study was to identify factors related to the advancement of the colonoscope when the variable stiffness function is activated.

METHODS

Prospective study enrolling consecutive patients referred for colonoscopy. The variable stiffness colonoscope (Olympus CF-H180DI/L®) was used. We performed univariate and multivariate analyses of factors associated with the success of the variable stiffness function.

RESULTS

After the data inclusion period, 260 patients were analyzed. The variable stiffness function was used most in the proximal colon segments (ascending and transverse colon 85%; descending/sigmoid colon 15.2%). The body mass index was lower in patients in whom the endoscope advanced after activating the variable stiffness than those in which it could not be advanced (25.9 + or - 4.8 vs. 28.3 + or - 5.4 kg/m2, p = 0.009). The endoscope advanced less frequently when the stiffness function was activated in the ascending colon versus activation in other segments of the colon (25% vs. 64.5% ascending colon vs. other segments; p < 0.05). In the multivariate analysis, only the colon segment in which the variable stiffness was activated was an independent predictor of advancement of the colonoscope.

CONCLUSIONS

The variable stiffness function is effective, allowing the colonoscope advancement especially when applied in the transverse colon, descending colon and sigmoid. However, when used in the ascending colon it has a lower effectiveness.

Study of cadmium, zinc and lead biosorption by orange wastes using the subsequent addition method

The biosorption of several metals (Cd2+, Zn2+ and Pb2+) by orange wastes has been investigated in binary systems. Multicomponent sorption isotherms were obtained using an original procedure, similar to that proposed by Pagnanelli et al. [Pagnanelli, F., Petrangeli, M.P., Toro, L., Trifoni, M., Veglio, F., 2001a. Biosorption of metal ions on Arthrobacter sp.: biomass characterization and biosorption modelling. Environ. Sci. Technol. 34, 2773-2778] for monoelement systems, known as subsequent addition method (SAM). Experimental sorption data were analysed using an extended multicomponent Langmuir equation. The maximum sorption uptake was approximately 0.25mmol/g for the three binary systems studied. The reliability of the proposed procedure for obtaining the equilibrium data in binary systems was verified by means of a statistical F-test.

Factors associated with non-attendance at outpatient endoscopy

OBJECTIVE

Non-attendance at endoscopy procedures leads to wasted resources and increased costs. The purpose of this study was to investigate the factors associated with non-attendance.

MATERIAL AND METHODS

All patients who attended the outpatient clinic for gastroscopy or colonoscopy examinations were included in the study. Patients who missed their appointment were identified and their data were collected prospectively. Patients who kept their appointment in the same period of time served as controls.

RESULTS

Between August 2002 and February 2003, 1051 gastroscopies and 756 colonoscopies were scheduled. A total of 265 patients (14.7%) missed their appointment. No significant differences were found between attendees and non-attendees for mean age, gender, type of examination and day of the week on which the examination was scheduled. The time on the waiting list was longer in patients who did not keep their appointment than in those who did. Fewer appointments were missed in patients with a preferent referral, and among patients referred by their general practitioner a higher percentage failed to keep their appointment compared with those referred by a specialist. In the multivariate analysis, length of time on the waiting list and the source of referral were the only two independent predictive factors for non-attendance.

CONCLUSIONS

A longer time on the waiting list and referral by a general practitioner are factors associated with patients failing to keep their endoscopy appointment.

[Passive smoking as a cerebrovascular risk factor]

INTRODUCTION

Stroke is one of the main causes of morbidity and mortality in developed countries today. Smoking is a risk factor that is associated with arteriosclerotic disease.

AIM

To evaluate the risk of having a stroke associated to both active and passive smoking in a case-control study.

PATIENTS AND METHODS

A case-control study was conducted which included 151 stroke patients who were admitted to hospital in the Neurology Service at the Hospital General Universitario in Alicante over a 12-month period. The control group (302) was obtained from patients who visited the emergency department at the hospital with no history of strokes and who reported clinical signs and symptoms that were not compatible with a stroke. The cases and controls were paired according to age and sex, including two controls of the same sex and whose ages were within a year of that of each case which was obtained.

RESULTS

The mean age of the patients was 70.6 years (range: 59-81 years). Males predominated in the sample (57.6%). Stroke patients had a significantly higher percentage of hypertension, peripheral arterial disease, heart disease and dyslipidemia than the control group. The most frequently affected vascular territory was the carotid (33.8%). The most frequent presenting symptom of the stroke was motor syndrome together with language disorders (39.4%). The risk of suffering a stroke associated to active smoking was 1.40 (CI 95% = 0.91-2.15) and in the case of passive smoking it was 1.45 (CI 95% = 0.82-2.58).

CONCLUSIONS

The findings from this study suggest there is a relevant association between environmental exposure to tobacco smoke and increased vascular risk (which confirms other results that have been published in the literature) and stress how important it is for non-smokers to find smoke-free zones.

Removal of cadmium from aqueous solutions by adsorption onto orange waste

The use of orange wastes, generated in the orange juice industry, for removing cadmium from aqueous solutions has been investigated. The material was characterized by Fourier transform infrared spectroscopy and batch experiments were conducted to determine the adsorption capacity of the biomass. A strong dependence of the adsorption capacity on pH was observed, the capacity increasing as pH value rose. Kinetics and adsorption equilibrium were studied at different pH values (4-6). The adsorption process was quick and the equilibrium was attained within 3h. The maximum adsorption capacity of orange waste was found to be 0.40, 0.41 and 0.43 mmol/g at pH 4-6, respectively. The kinetic data were analysed using various kinetic models - pseudo-first order equation, pseudo-second order equation, Elovich equation and intraparticle diffusion equation - and the equilibrium data were tested using four isotherm models - Langmuir, Freundlich, Sips and Redlich-Peterson. The data were fitted by non-linear regression and five error analysis methods were used to evaluate the goodness of the fit. The Elovich equation provides the greatest accuracy for the kinetic data and the Sips model the closest fit for the equilibrium data.

Clinical value of rapid urine trypsinogen-2 test strip, urinary trypsinogen activation peptide, and serum and urinary activation peptide of carboxypeptidase B in acute pancreatitis

AIM

To assess the usefulness of urinary trypsinogen-2 test strip, urinary trypsinogen activation peptide (TAP), and serum and urine concentrations of the activation peptide of carboxypeptidase B (CAPAP) in the diagnosis of acute pancreatitis.

METHODS

Patients with acute abdominal pain and hospitalized within 24 h after the onset of symptoms were prospectively studied. Urinary trypsinogen-2 was considered positive when a clear blue line was observed (detection limit 50 microg/L). Urinary TAP was measured using a quantitative solid-phase ELISA, and serum and urinary CAPAP by a radioimmunoassay method.

RESULTS

Acute abdominal pain was due to acute pancreatitis in 50 patients and turned out to be extrapancreatic in origin in 22 patients. Patients with acute pancreatitis showed significantly higher median levels of serum and urinary CAPAP levels, as well as amylase and lipase than extrapancreatic controls. Median TAP levels were similar in both groups. The urinary trypsinogen-2 test strip was positive in 68% of patients with acute pancreatitis and 13.6% in extrapancreatic controls (P<0.01). Urinary CAPAP was the most reliable test for the diagnosis of acute pancreatitis (sensitivity 66.7%, specificity 95.5%, positive and negative predictive values 96.6% and 56.7%, respectively), with a 14.6 positive likelihood ratio for a cut-off value of 2.32 nmol/L.

CONCLUSION

In patients with acute abdominal pain, hospitalized within 24 h of symptom onset, CAPAP in serum and urine was a reliable diagnostic marker of acute pancreatitis. Urinary trypsinogen-2 test strip showed a clinical value similar to amylase and lipase. Urinary TAP was not a useful screening test for the diagnosis of acute pancreatitis.

Improvement of coagulation-flocculation process using anionic polyacrylamide as coagulant aid

A physicochemical treatment (coagulation-flocculation) was applied to a slaughterhouse wastewater, using anionic polyacrylamide as coagulant aid to improve the settling velocity of the flocs formed with the coagulants used: ferric sulphate, aluminium sulphate and polyaluminium chloride. The optimum speed and stirring time for the flocculation stage were ascertained along with the optimum pH and coagulant and coagulant aid doses. The speed and coagulation time were initially set according to recommendations in the literature concerning the treatment of this type of water. Chemical oxygen demand (COD), biochemical oxygen demand at 5 days (BOD5) and total suspended solids (TSS) were recorded at the beginning and end of each experiment in order to monitor the process. Once the optimal conditions had been established, several parameters were measured in order to assess the coagulation-flocculation process: particle number and size, sludge volume, nutrients (ammonia nitrogen, total Kjeldahl nitrogen, albuminoid nitrogen, orthophosphate, total phosphorus) and the residual concentration of iron and aluminium in clarified water. Anionic polyacrylamide, when added with ferric sulphate or polyaluminium chloride led to a significant increase in the settling speed.

[Proteinuria and urinary beta 2-microglobulin as markers of tubular malfunction in the assessment of severity of acute pancreatitis]

INTRODUCTION

Proteinuria is a common finding in acute pancreatitis (AP). Increased urinary beta 2-microglobulin can be explained by renal tubular malfunction induced by substances released from the pancreas. The degree of renal tubular malfunction may reflect the severity of AP.

AIM

To assess proteinuria and urinary beta 2-microglobulin as prognostic factors in AP.

PATIENTS AND METHODS

We retrospectively studied patients with AP with symptom onset within 24 hours before admission. Random urine specimens were obtained on days 1, 2 and 3 after admission. In a subgroup of 25 patients, urine samples could be obtained within 24 hours of symptom onset on day 1. The severity of AP was established using the Atlanta criteria. Proteinuria and beta 2-microglobulin were determined and were adjusted by urinary creatinine concentrations.

RESULTS

We studied 51 patients with AP (26 men and 25 women; age: 59.6 (+/-16.7 years). Fifteen cases of AP were severe and 36 were mild. The most frequent etiology was gallstones (60.1%). Levels of proteinuria were (median and interquartile range) in mg/g creatinine: day 1: 180.5 (84.0-250.9), day 2: 164.3 (16.7-421.7), and day 3: 136.7 (24.0-371.29). Differences between severe and mild AP were significant on day 2 of admission: 339.7 (191.7-471.8) versus 120,1 (11.0-382.6); p = 0.04. Levels of urinary beta 2-microglobulin in AP on days 1 to 3 postadmission were: 9.7 (1.1-93.3), 27.6 (4.7-421.4) and 88.3 (7.3-415.2) microg/mg of creatinine, respectively. When urinary beta 2-microglobulin was compared between severe and mild AP, no significant differences were found among days 1, 2 and 3. Selection of only the subgroup of patients whose urine samples were obtained within 24 h of symptom onset, did not improve the results of these urine markers for the group as a whole.

CONCLUSIONS

1) Proteinuria was slightly increased in severe AP and was able to discriminate between mild and severe episodes on day 2 of admission. 2) Urinary beta 2-microglobulin as a tubular malfunction marker did not discriminate between mild and severe AP in patients in our study.

A comparative study of the activation peptide of carboxypeptidase B and trypsinogen as early predictors of the severity of acute pancreatitis

BACKGROUND

Serum and urine concentrations of the activation peptide of carboxypeptidase B (CAPAP) and urinary trypsinogen activation peptide (TAP) as prognostic markers in acute pancreatitis were compared.

METHOD

Fifty-two patients with acute pancreatitis hospitalized within 24 hours after symptom onset were prospectively studied. Blood and urine samples were obtained during the first 3 days of the hospital stay.

RESULTS

Pancreatitis was severe in 17 patients and mild in 35 (Atlanta criteria). Median serum CAPAP levels on days 1 and 2 and of urine CAPAP and TAP on days 1, 2, and 3 were significantly higher in severe pancreatitis than in mild disease. On the first day of admission, TAP was the most accurate predictor of severity (sensitivity, 92.3%; specificity, 80%; positive and negative predictive values, 63.2% and 96.6%, respectively), with a 4.61 positive likelihood ratio for a cutoff value of 18.10 nmol/L, whereas within 24 hours after symptom onset, urinary CAPAP was superior (sensitivity, 88.9%; specificity, 81.3%; positive and negative predictive values 72.7% and 92.9%, respectively), with a 4.72 positive likelihood ratio for a cutoff value of 15.45 nmol/L.

CONCLUSION

Serum and urine CAPAP levels and urinary TAP are accurate in the early assessment of severity in acute pancreatitis. Urine CAPAP levels was the most accurate marker 24 hours after onset of symptoms.

A study of intestinal permeability in relation to the inflammatory response and plasma endocab IgM levels in patients with acute pancreatitis

BACKGROUND

There is scarce information regarding intestinal permeability (IP) in patients with acute pancreatitis (AP) and its relationship with systemic inflammatory response and bacterial translocation (BT).

AIMS

To study IP in patients with mild and severe forms of AP as compared with controls and the presumed correlations between IP, the inflammatory response, and endotoxin.

PATIENTS AND METHODS

Sixty-eight patients with AP and 13 healthy controls were included. IP was assessed by means of the lactulose/mannitol (L/M) test, at admission (LMR1), and at the 15th day (LMR2). The presence of endotoxin was assessed by means of endotoxin-core antibodies type IgM (EndoCab IgM), at admission and 15 days later in patients with severe AP. Plasma levels of interleukins 6, 8, 10, and tumor necrosis factor alpha were tested within the first 72 hours from the onset of pain.

RESULTS

Both LMR1 and LMR2 were significantly higher in patients than in controls, and in patients with severe versus mild forms of AP. Plasma levels of Endocab IgM increased significantly in patients with severe AP. Basal plasma levels of pro- and anti-inflammatory cytokines were significantly higher in patients with severe AP. A significant correlation was found between LMR2 and Endocab IgM levels in patients with severe AP (r = 0.73, P = 0.02).

CONCLUSIONS

Patients with AP show an increased IP when compared with controls, being more relevant and persistent in severe cases. This seems related to an increase of endotoxemia late in the course of the disease, but not with an exacerbation of the systemic immune response.

Factors predicting mortality in severe acute pancreatitis

Acute pancreatitis (AP) is a common disorder in which ensuing serious complications may lead to a fatal outcome in patients.

BACKGROUND/AIMS

To describe a large series of patients with severe AP (SAP) who were admitted to our hospital and to identify factors predicting mortality.

PATIENTS AND METHODS

In a retrospective study, all patients with SAP diagnosed between February 1996 and October 2000 according to the Atlanta criteria were studied.

RESULTS

Out of a total of 363 AP patients, 67 developed SAP. The mean age of the patients was 69; the commonest etiology was biliary; 55.2% developed necrosis; the commonest systemic complication was respiratory failure (44.7%), followed by acute renal failure (35.8%) and shock (20.9%). A total of 31.3% of the patients died. Factors significantly related to mortality were age, upper digestive tract bleeding, acute renal failure, respiratory failure and shock by univariate analysis. However, pseudocysts seemed to have a protective effect. By multivariate analysis, independent prognostic factors were age, acute renal failure and respiratory failure.

CONCLUSIONS

Patients with SAP mainly died due to systemic complications, especially acute renal failure and respiratory failure. Necrosis (in the absence or presence of infection) was not correlated with increased mortality. A pseudocyst was found to be a protective factor, probably because the definition itself led to the selection of patients who had survived multiorgan failure.

Early measurement of procalcitonin does not predict severity in patients with acute pancreatitis

Measurement does not predict severity

Comparison of stool immunoassay with standard methods for detection of Helicobacter pylori infection in patients with upper-gastrointestinal bleeding of peptic origin

OBJECTIVE

To assess the accuracy of the determination of Helicobacter pylori infection by a stool immunoassay in patients with upper-gastrointestinal bleeding (UGB) of peptic origin, in comparison with the routine histological study, serology, rapid urease and 13C-breath tests.

METHODS

Sixty-eight patients with endoscopically proven UGB of peptic origin were included. The presence of H. pylori was considered when observed on histology or, if negative, by the positive indications of two of the remaining tests (serology, rapid urease,13C-breath test). The accuracy of stool immunoassay was estimated according to results obtained with other diagnostic methods.

RESULTS

Lesions causing gastrointestinal bleeding were 49 duodenal ulcers, 11 gastric ulcers, six pyloric channel ulcers, 13 acute lesions of the gastric mucosa, and 16 erosive duodenitis. H. pylori infection was present in 59 (86.76%) patients. Forty-one patients had received nonsteroidal anti-inflammatory drugs. The sensitivity and specificity of the diagnostic methods were 47.5% and 100% for the rapid urease test, 93% and 87.5% for the breath test, 86.4% and 77.7% for serology, 89.4% and 100% for histology, and 96.6% and 33.3% for the stool test.

CONCLUSIONS

The detection of H. pylori antigen in stools in patients with UGB of peptic origin has a good sensitivity (96.6%) but a low specificity (33.3%) for the diagnosis of H. pylori infection, which probably makes this test an inadequate tool in this setting if utilized alone.

Microscopic observation of particle reduction in slaughterhouse wastewater by coagulation-flocculation using ferric sulphate as coagulant and different coagulant aids

A coagulation-flocculation treatment has been applied to a slaughterhouse liquid effluent, using ferric sulphate as coagulant and activated silica, powdered activated carbon, cationic polyacrylamide, polyvinyl alcohol, polyacrylic acid and anionic polyacrylamide as coagulant aids in order to improve the settling time. Once the optimal conditions had been established (speed and time of stirring during flocculation step, pH, coagulant and coagulant aid doses), the efficiency of the coagulation-flocculation process was studied by comparing the particle size distribution before and after the addition of the coagulant. When ferric sulphate was used without the coagulant aids, particle removal efficiency varied with size, although overall efficiency was quite substantial (87%). The use of coagulant aids improved the removal efficiency, except in the case of activated silica, when it fell to 78%. In all other cases removal efficiency values between 93% (for polyvinyl alcohol) and 99% (for anionic polyacrylamide) were reached.

Nutrient removal and sludge production in the coagulation-flocculation process

Nutrient removal and sludge production in the coagulation-flocculation process, applied to a slaughterhouse effluent, have been studied. Fe2(SO4)3, Al2(SO4)3 and polyaluminium chloride were used as coagulants. Inorganic products were used as coagulant aids: activated silica, powdered activated carbon and precipitated calcium carbonate and synthetic polyelectrolytes: cationic polyacrylamide, polyacrilic acid, anionic polyacrylamide and polyvinyl alcohol. Performances were measured under optimum conditions for the products used. They were found after studying the different variables which influence the process. Phosphorus removal is very high (approximately 100% for the orthophosphate and between 98.93% and 99.90% for the total phosphorus). Ammonia nitrogen removal is very low although appreciable performances are observed for albuminoid nitrogen (73.9-88.77%). The use of coagulant aids reduces the volume of the sludge produced up to 41.6%.

Antimalarial activity of neurolenin B and derivates of Eupatorium inulaefolium (Asteraceae)

Dried stems and leaves of Eupatorium inulaefolium (Austroeupatorium inulaefolium) (Asteraceae) were used to obtain four crude extracts (hexane, dichloromethane, methanol and ethanol). Two fractions were obtained from the hexane extract (S1 and S2) and three compounds (neurolenin B, lobatin A and lobatin B) from the dichloromethane extract. The ethanol, hexane, dichloromethane and methanol extracts, two fractions from the hexane extract (S1 and S2), and neurolenin B were evaluated in vitro against Plasmodium falciparum, FCB-2 strain. Two extracts (dichloromethane and methanol), the S2 fraction and neurolenin B showed statistically significant antiplasmodial activity.

Comparison of diagnostic methods for Helicobacter pylori infection in patients with upper gastrointestinal bleeding

BACKGROUND

Accuracy of the most frequently used tests for diagnosing Helicobacter pylori infection in patients with upper gastrointestinal bleeding of peptic origin is determined.

METHODS

Seventy-eight patients with endoscopically-proven upper gastrointestinal bleeding of peptic origin were included. The presence of H. pylori was considered when observed from the histology or, if negative, when serology and breath test were both positive. Accuracy of the rapid urease test was estimated in accordance with results obtained with other diagnostic methods.

RESULTS

Lesions causing gastrointestinal bleeding were 56 duodenal ulcers, 13 gastric ulcers, 7 pyloric channel ulcers, 13 acute lesions of the gastric mucosa and 16 erosive duodenitis. H. pylori infection was present in 68 patients (87.2%). Forty-four patients had received non-steroidal anti-inflammatory drugs. The sensitivity/specificity (%) of the diagnostic methods was 48.5/100 for the rapid urease test, 91/77.8 for the breath test, 89.5/80 for serology and 86.3/100 for histology. The prior consumption of proton-pump inhibitors and antibiotics induced false-negative results in the rapid urease test and breath test, with no effect on serology and histology.

CONCLUSIONS

The prevalence of H. pylori infection in patients with upper gastrointestinal bleeding from peptic lesions is high. Sensitivity of the rapid urease test for diagnosing H. pylori is low in this setting. Cases with negative rapid urease test need the combination of two or more additional tests if diagnosis is to be achieved. Cases with positive rapid urease test do not need further investigation for diagnosis.

[Premature labor with intact membranes: microbiology of the amniotic fluid and lower genital tract and its relation with maternal and neonatal outcome]

BACKGROUND

The prevalence of idiopathic spontaneous premature labor or without an evident clinical cause, has not been reduced with tocolytic treatments, suggesting that premature labor has multiple causes and infections play a not well-defined role.

AIM

To perform microbiological studies of the amniotic fluid and of the lower genital tract in women with idiopathic premature labor and intact membranes, relating these findings with maternal and neonatal outcomes.

PATIENTS AND METHODS

Women with pregnancies between 24 and 34 weeks, with premature labor and without an evident clinical cause were enrolled. Amniotic fluid and genital tract samples were obtained for traditional microbiological cultures. This information was related with delivery events and neonatal outcome.

RESULTS

Sixty-three patients were included. The overall frequency of microbial invasion of amniotic cavity was 23.8% and of cervical or vaginal infection was 63.5% (in 39.7% there was only cervical or vaginal infection without involvement of the amniotic sac). Absence of infection was documented in 36.5% of women. Compared to patients without infection, women with microbial invasion of amniotic cavity had a higher rate of prematurity (73.3% p < 0.05), a higher rate of prematurity of less than 34 weeks (60% p < 0.01), a higher frequency of preterm rupture of membranes (40% p < 0.001), a shorter admission-to-delivery interval (median 3.0 days p < 0.01) and lower gestational age at delivery (median 33 weeks p < 0.01). Clinical chorioamnionitis and endometritis (20% p < 0.01) was observed only in patients with amniotic cavity infections. Severe asphyxia (26.7% p < 0.05) and neonatal admission to Intensive Care Units (46.7% p < 0.05) were more frequent and neonatal weight was less in the offspring of women with microbial invasion of amniotic cavity (2020 g median p < 0.01).

CONCLUSIONS

In preterm labor with intact membranes, intraamniotic infection is the most frequent cause of prematurity and is associated with a higher prevalence of maternal and neonatal problems.

[Behavior disorders during REM sleep. Two clinical cases]

INTRODUCTION

The behavior disorder occurring during REM (Rapid Eye Movement) sleep is a parasomnia characterized by absence of atonia typical of this phase of sleep, although the other characteristics are maintained, namely rapid eye movements and desynchronization of cortical electrical activity. Clinically it is accompanied by abrupt, often violent movements, which may involve a limb or the trunk in relation to dreams typical of this phase of sleep, and which may interrupt sleep. Many pathological processes have been described, including: the Shy-Dragger syndrome, Parkinson's disease, olivopontocerebellar atrophy, multisystemic atrophy, in relation to certain antidepressant drugs, and most frequently the idiopathic form.

CLINICAL CASES

We present two cases, one diagnosed as olivopontocerebellar atrophy and another in which there were no pathological findings. Both were referred to our department for the study of possible sleep disorders. In both cases neurophysiological studies, basically polysomnography with monitorization of various muscle groups and video, led to the diagnosis.

CONCLUSIONS

We discuss the diagnostic and physiological criteria, and physiopathological explanations of each case, with special reference to N-Methyl-D-Aspartate (NMDA) and non-N-Methyl-D-Aspartate (non-NMDA) receptors. Finally we consider the pharmacological treatment of this disorder.

[Neurophysiological study in Alpers syndrome]

INTRODUCTION

Infantil progressive polydystrophy was described by Alpers in a child with psychomotor retardation, crises which were resistant to treatment and diffuse loss of cortical neurons.

OBJECTIVE

The aim of this study was to review the neurophysiological aspects of Alpers syndrome and their clinical correlation.

MATERIAL AND METHODS

We present three children with subacute encephalopathy, progressive psychomotor retardation, myoclonic epilepsy which was resistant to treatment and crises of apnea, who had degeneration of the cerebral grey matter. Serial EEG, polysomnographs, auditory evoked potentials of the brain stem and visual evoked potentials were done.

RESULTS

The electroencephalogram findings showed the presence of complex bursts of acute waves, small many-pointed or slow waves of great amplitude which were irregular and arrhythmical, lasting one to five seconds, separated by periods of inactivity on the tracing which lasted from three to ten seconds. The EEG was distinctive, changing over the course of the illness, and with increasing numbers and duration of the bursts of suppression of cerebral bioelectric activity. Polysomnography showed cerebral bioelectric activity which was markedly unstructured and with little difference between the tracings when asleep and when awake, together with a large number of apneas of obstructive and mixed types. The PEAT showed reduced amplitude and altered morphology in all the waves, and even absence of some of them. The visual evoked potentials were asymmetrical and with delay in the latency of the P100 wave.

CONCLUSIONS

Although definite diagnosis of progressive neurone degeneration requires post mortem examination of the brain, clinico-pathological studies, including electrophysiological, radiological and biochemical studies are sufficiently characteristic to suggest the diagnosis during life.

[Neurophysiological aspects of Proteus syndrome]

INTRODUCTION

The Proteus Syndrome was defined in 1983 by Wiedeman. However, the first case mentioned in the literature was that of Joseph Merrick, the Elephant Man, presented by Sir Frederick Treves in 1884. It is a rare pathological condition. Its multiple clinical features include; partial gigantism of hands and/or feet, pigmented nevi, hemihypertrophy of the body, tumors, skeletal anomalies, growth disorders and visceral anomalies. Hereditary transmission has not been clearly defined. Diagnosis and treatment require the participation of experts from several medical and surgical specialties.

CLINICAL CASE

We present a case sent to our hospital for the surgical correction of cranio-facial malformations. Epileptic crises post-operatively indicated the need for neurological and neuro-physiological study. This was done by means of conventional electro-encephalography: brainstem, somato-sensorial and visual auditory evoked potentials, together with imaging techniques which showed the structural and functional asymmetry of the central nervous system at both cerebral and brainstem levels.

CONCLUSIONS

Few neuro-physiological studies are included in the literature we reviewed for this paper. Therefore we do not know whether the functional anomalies of the central nervous system which we describe should be considered to be part of the syndrome.

Lipomatous hypertrophy of the cardiac interatrial septum

A case of lipomatous hypertrophy of the cardiac interatrial septum is reported in a 91-year-old man who attempted to commit suicide. The lesion was found incidentally at autopsy. Gross examination showed a 3.5-cm mass, yellow and firm. Histologic study showed a proliferation of mature fat cells and slightly hypertrophic cardiac muscle cells.

Overexpression of copper-zinc superoxide dismutase in trisomy 21

Down's syndrome (DS), the most frequent of congenital birth defects, results from the trisomy of chromosome 21 in all cells of affected patients. This disease is characterized by developmental anomalies, mental retardation and features of rapid aging, particularly in the brain, where the occurrence of Alzheimer's disease is observed in trisomy 21 patients over the age of 35. Copper-zinc superoxide dismutase (CuZnSOD) is one of the proteins encoded by chromosome 21 (21q22.1). As a consequence of gene dosage excess, CuZnSOD activity is increased by 50% in all DS tissues. This work reports the SOD activity of a population of DS patients with complete trisomy 21, partial trisomy 21, translocations and mosaicism, in order to confirm the gene dosage effect of SOD on the clinical features of DS, and to help to establish which is the critical region of chromosome 21 in DS. CuZnSOD was measured in red blood cells using the Minami and Yoshikawa method. In the population with complete trisomy 21, SOD activity was increased by 42%; in the population with partial trisomy 21, translocations and mosaicism, SOD activity was normal. In the population diagnosed as DS, but not karyotyped, SOD activity was increased by 28%. No differences between sexes or among ages were found. We conclude that the 21q22.1 segment is not the critical region responsible for DS, as we have found normal SOD activity in patients with the clinical features of DS.

Selective chiral inhibition of Ca2+ entry promoted by bisbenzyltetrahydroisoquinolines in rat uterus

The effects of diltiazem and six bisbenzyltetrahydroisoquinoline alkaloids (antioquine, 7-O-methylantioquine, dimethylantioquine, monterine, granjine and cordobimine) were studied in rat isolated uterus in order to clarify the mechanisms of their relaxant actions. All the compounds tested completely relaxed KCl-induced contractions and totally or partially inhibited oxytocin-induced rhythmic contractions. Only alkaloids with absolute configurations (1R,1'S or 1R,1'R) acted intracellularly, promoting relaxation of contractile responses induced by oxytocin in a Ca(2+)-free medium, as does papaverine. Alkaloids of the antioquine series (1S,1'R) selectively inhibited Ca2+ entry. The great rigidity of these structures and their stereoselective action make these alkaloids useful in studies of the conformational features of the Ca2+ channel.

Neonatal respiratory distress syndrome (RDS) in cases of premature labor treated by betamimetic drugs

In 87 premature labors, 31 were treated with betamimetic drugs. The incidence of RDS in the treated group has been lower than in the non-treated group, especially when gestational age was shorter than 35 wk and when newborn's weight was lower than 2000 g.