The HERA (Hyper-response Risk Assessment) Delphi consensus for the management of hyper-responders in in vitro fertilization

PURPOSE

To provide agreed-upon guidelines on the management of a hyper-responsive patient undergoing ovarian stimulation (OS) METHODS: A literature search was performed regarding the management of hyper-response to OS for assisted reproductive technology. A scientific committee consisting of 4 experts discussed, amended, and selected the final statements. A priori, it was decided that consensus would be reached when ≥66% of the participants agreed, and ≤3 rounds would be used to obtain this consensus. A total of 28/31 experts responded (selected for global coverage), anonymous to each other.

RESULTS

A total of 26/28 statements reached consensus. The most relevant are summarized here. The target number of oocytes to be collected in a stimulation cycle for IVF in an anticipated hyper-responder is 15-19 (89.3% consensus). For a potential hyper-responder, it is preferable to achieve a hyper-response and freeze all than aim for a fresh transfer (71.4% consensus). GnRH agonists should be avoided for pituitary suppression in anticipated hyper-responders performing IVF (96.4% consensus). The preferred starting dose in the first IVF stimulation cycle of an anticipated hyper-responder of average weight is 150 IU/day (82.1% consensus). ICoasting in order to decrease the risk of OHSS should not be used (89.7% consensus). Metformin should be added before/during ovarian stimulation to anticipated hyper-responders only if the patient has PCOS and is insulin resistant (82.1% consensus). In the case of a hyper-response, a dopaminergic agent should be used only if hCG will be used as a trigger (including dual/double trigger) with or without a fresh transfer (67.9% consensus). After using a GnRH agonist trigger due to a perceived risk of OHSS, luteal phase rescue with hCG and an attempt of a fresh transfer is discouraged regardless of the number of oocytes collected (72.4% consensus). The choice of the FET protocol is not influenced by the fact that the patient is a hyper-responder (82.8% consensus). In the cases of freeze all due to OHSS risk, a FET cycle can be performed in the immediate first menstrual cycle (92.9% consensus).

CONCLUSION

These guidelines for the management of hyper-response can be useful for tailoring patient care and for harmonizing future research.

Cardio4Health Study, a Cardiac Telerehabilitation Pilot Program Aimed at Patients After an Ischemic Event: Cross-sectional Study

BACKGROUND

Center-based cardiac rehabilitation programs (CRPs) reduce morbidity and mortality after an ischemic cardiac event; however, they are widely underused. Home-based CRP has emerged as an alternative to improve patient adherence; however, its safety and efficacy remain unclear, especially for older patients and female patients.

OBJECTIVE

This study aimed to develop a holistic home-based CRP for patients with ischemic heart disease and evaluate its safety and impact on functional capacity, adherence to a healthy lifestyle, and quality of life.

METHODS

The 8-week home-based CRP included patients of both sexes, with no age limit, who had overcome an acute myocardial infarction in the previous 3 months, had a left ventricular ejection fraction of ≥40%, and had access to a tablet or mobile device. The CRP was developed using a dedicated platform designed explicitly for this purpose and included 3 weekly exercise sessions combining tailored aerobic and strength training and 2 weekly educational session focused on lifestyle habits, therapeutic adherence, and patient empowerment.

RESULTS

We initially included 62 patients, of whom 1 was excluded for presenting with ventricular arrhythmias during the initial stress test, 5 were excluded because of incompatibility, and 6 dropped out because of a technological barrier. Ultimately, 50 patients completed the program: 85% (42/50) were male, with a mean age of 58.9 (SD 10.3) years, a mean left ventricular ejection fraction of 52.1% (SD 6.72%), and 25 (50%) New York Heart Association functional class I and 25 (50%) New York Heart Association II-III. The CRP significantly improved functional capacity (+1.6 metabolic equivalent tasks), muscle strength (arm curl test +15.5% and sit-to-stand test +19.7%), weekly training volume (+803 metabolic equivalent tasks), adherence to the Mediterranean diet, emotional state (anxiety), and quality of life. No major complications occurred, and adherence was excellent (>80%) in both the exercise and educational sessions. In the subgroup analysis, CRP showed equivalent beneficial effects irrespective of sex and age. In addition, patient preferences for CRP approaches were equally distributed, with one-third (14/50, 29%) of the patients preferring a face-to-face CRP, one-third (17/50, 34%) preferring a telematic CRP, and one-third (18/50, 37%) preferring a hybrid approach. Regarding CRP duration, 63% (31/50) of the patients considered it adequate, whereas the remaining 37% (19/50) preferred a longer program.

CONCLUSIONS

A holistic telematic CRP dedicated to patients after an ischemic cardiac event, irrespective of sex and age, is safe and, in our population, has achieved positive results in improving maximal aerobic capacity, weekly training volume, muscle strength, quality of life, compliance with diet, and anxiety symptoms. The preference for a center- or home-based CRP approach is diverse among the study population, emphasizing the need for a tailored CRP to improve adherence and completion rates.

P-779 Single (SET) versus double embryo transfer (DET) in PGT-A cycles: cumulative live birth rates (CLBR) and multiple pregnancy rates using a Markov decision-analytic model

Study question

Is the SET of a euploid embryo in two sequential cycles associated with higher CLBR when compared to DET of euploid embryos in one cycle?

Summary answer

Two sequential SET of euploid embryos is associated with higher CLBR and lower multiple pregnancy rate compared to DET of euploid embryos

What is known already

Infertile couples seek ART treatment with the goal of achieving the birth of a healthy child. A growing number of clinicians propose an IVF, preimplantation genetic testing for aneuploidy (PGT-A), and freeze-all plan, as a strategy to shorten the time to pregnancy, increase the efficiency of the treatment process, and the chance of a successful LB. Amid its benefits, a pivotal question remains when ≥2 euploid embryos are available: what is associated with more births, the transfer of two embryos in one cycle, or transfer one embryo in two sequential cycles?

Study design, size, duration

Multicenter (Mexico, Brazil and Argentina), retrospective observational study. The study analyzed clinical outcomes of two strategies from three centers. A total of 965 autologous IVF cycles were identified, of which 611 met the inclusion criteria of use of an IVF cycle with a freeze-all protocol with trophectoderm biopsy and PGT-A testing between January 2017 to February 2021.

Participants/materials, setting, methods

Cohorts were segregated into: Group 1) one double embryo transfer (DET) cycle (95 cycles); Group 2) two single embryo transfer (SET) cycles (516 cycles). Cycle outcomes (no pregnancy, biochemical loss, clinical loss (after detection of fetal heart), live birth, and multiple pregnancy were calculated, along with the cumulative percentage of patients who achieved a LB on each treatment path. A 95% CI was reported for all calculations.

Main results and the role of chance

There was no statistical difference between age, AMH, and BMI between groups. In Group 1 DET, 64.2% of patients achieved a LB, with 35.3% of multiples (twin gestation). Of the 35.8% that did not achieve a LB, 27.5% had a biochemical loss, 18.5% had a clinical loss and 53.9% were not pregnant. The cumulative LBR in Group 2SET was 81.9% (58.1% in cycle 1 and 23.8% in cycle 2 of the 41.9% that did not achieve a LB in cycle 1) with a 98.5% singleton rate. Per cycle, the LBR in cycle 1 was 58.1%; from the 41.9% that did not achieve a LB, 21.5% had a biochemical loss, 23.7% had a clinical loss, and 54.8% were not pregnant. LBR in cycle 2 was 56.9%; from the 42.1% that did not achieve an LB, 31.1% had a biochemical loss, 11.3 clinical loss, and 57.6% were not pregnant.

Limitations, reasons for caution

Retrospective study. Although most of the patients who underwent a PGT cycle were characteristically ‘good’ responders, this study was not limited to them. Third, we recognize that not all patients, regardless of response, develop high-quality blastocysts; therefore, this approach is not suitable for every patient.

Wider implications of the findings

The study demonstrates that in the modern era of ART, transferring two embryos is not associated with higher success rates and is associated with higher multiple pregnancy rates. Compared to one DET cycle, patients who pursued two SET cycles achieved 17.7% higher LBR when 2 euploid embryos were available.

Trial registration number

not applicable

P-648 Intramuscular progesterone as a rescue therapy for optmized luteal phase support in patients with low progesterone levels during elective euploid single embryo transfer

Study question

Does the addition of intramuscular progesterone(P) may improve the clinical outcomes of FET cycles in cases of low serum P levels before embryo transfer?

Summary answer

Intramuscularly P may correct the potentially harmful effects associated with low serum P levels during the luteal phase in FET cycles performed under HRT.

What is known already

Compelling evidence suggests that during FET, P levels measured on the mid-luteal phase may impact pregnancy outcomes, indicating that regardless of uterine P levels, a minimum level of serum P is required to enhance clinical outcomes. Up to one-third of patients under HRT using intravaginal micronized progesterone during FET cycles may present inadequate serum P levels, which may decrease the live birth rate in up to 32% when compared to patients with adequate serum P levels. Thus, the individualization of the LPS according to P monitoring may be necessary to overcome the deleterious effect of low P levels before FET.

Study design, size, duration

A retrospective cohort study was conducted between August 2019 and June 2021. Patients undergoing elective single embryo transfer (eSET) of euploid day 5 or day 6 blastocysts with own oocytes were included in the study. During the study period, 305 patients fulfilled the inclusion criteria.

Participants/materials, setting, methods

In patients presenting with serum P levels <9.2 ng/mL on the day before the ET, 1 mg/day of intramuscular P was added as a rescue therapy on the day of the ET and was maintained until the blood pregnancy test was completed; this represented the rescue LPS (rLPS) group. The clinical outcomes of rLPS group were compared to those patients with adequate serum P levels that maintained the LPS with vaginal micronized P (tLPS group).

Main results and the role of chance

During the study period, 305 patients fulfilled the inclusion criteria. There were 198 patients (65%) with adequate serum P levels that maintained the LPS with vaginal micronized and oral P (tLPS group), while 107 patients (35%) presented with low P levels in which a rescue intramuscularly administered P was added on the day of the embryo transfer (rLPS). When comparing the groups, there was no statistical difference in terms of maternal age, BMI, endometrial thickness before starting the P administration, estradiol and P levels in the proliferative phase, E levels in the luteal phase. There was a statistically significant difference in P levels on the day before the embryo transfer when comparing the tLPS and rLPS groups (13.6±6.2 ng/mL and 7.5±1.9 ng/mL, respectively; P<0.0001). No significant difference was observed in the clinical outcomes when comparing the tLPS and rLPS. The pregnancy rates were 73.7% and 72.0% (aOR=0.91, 95% CI 0.54–1.55; P=0.74), clinical pregnancy rates were 69.2% and 68.2% (aOR=0.96, 95% CI 0.58–1.55; P=0.86), and ongoing pregnancy rates were 65.7% and 64.5% (aOR=0.95, 95% CI 0.58–1.55; P=0.84) in the tLPS and rLPS respectively. The multivariate logistic regression did not identify any independent factor related to the ongoing pregnancy rate.

Limitations, reasons for caution

A control group comprising patients with low P levels that did not receive any intervention is lacking. However, we believe it would be unethical to neglect evidence from previous studies suggesting that low P levels might reduce reproductive outcomes in this group of patients.

Wider implications of the findings

Although previous clinical studies concluded that low luteal P levels before FET might impact clinical outcomes, we observed that intramuscular P administration starting on the day of euploid blastocyst ET, as a novel rescue therapy, can lead to comparable results to those achieved in patients presenting with adequate P levels.

Trial registration number

-

Cardiac telerrehabilitation: a safe and effective alternative in patients with coronary artery disease

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Ferrer Internaciona Groupl, S.A

Background

Center-based cardiac rehabilitation programs (CRP) have shown to reduce morbidity and mortality after an ischemic cardiac event, but their vastly underutilized. Home-based CRP seems to improve patient’s adherence, but there is still scarce evidence, especially in elderly patients and women.

Purpose

To develop a holistic home-based CRP for ischemic heart disease patients and evaluate its safety and impact on functional capacity, adherence to a heart-healthy lifestyle and quality of life.

Methods

The 8-week home-based CRP will include 60 patients (50% women) with no age limit who have suffered an acute myocardial infarction in the previous 3 months, with LVEF ≥40% and a tablet/mobile device. The CRP (Picture 1) includes 3 weekly exercise sessions combining tailored aerobic and strength training and 1 weekly educational session focused on lifestyle habits, therapeutic adherence, and patient empowerment.

Results

Between January and October 2021, 56 patients were included: 2 were rejected for presenting ventricular arrhythmias in the initial stress test and 4 due to technological barrier; 14 patients are currently performing the CRP. The preliminary results from the 36 patients who have completed the CRP show a significant increase in functional capacity, muscle strength, weekly training volume, adherence to Mediterranean diet, emotional state (anxiety) and quality of life (Picture 2). There have been no complications and patient’s adherence has been excellent for both exercise (85%) and educational (80%) sessions.

Conclusion

A holistic telematic CRP dedicated to patients after an ischemic cardiac event, including patients of both gender and of no age-limit, seems to be a feasible, safe and effective in improving maximal aerobic capacity, weekly training volume, muscle strength, quality of life, compliance with the Mediterranean diet and emotional state.

Training responsiveness of cardiorespiratory fitness and arterial stiffness following moderate-intensity continuous training and high-intensity interval training in adults with intellectual and developmental disabilities

BACKGROUND

Cardiorespiratory fitness (CRF) prompts antiatherogenic adaptations in vascular function and structure. However, there is an extraordinary interindividual variability in response to a standard dose of exercise, wherein a substantial number of adults with intellectual and developmental disabilities (IDD) do not improve CRF. We (1) evaluated the effects of 12-month of moderate-intensity continuous training (MICT) on CRF and arterial stiffness and (2) tested whether an additional 3-month of high-intensity interval training (HIIT) would add to improvements in CRF responsiveness and arterial stiffness.

METHODS

Fifteen adults with mild-to-moderate IDD (male adults = 9, 30.1 ± 7.5 years old) met 3 days per week for 30 min MICT for 12 months, after which the incidence of CRF responsiveness was calculated (≥5.0% change in absolute peak VO₂ ). Thereafter, responders and non-responders started HIIT for 3 months with identical daily training load/frequency. Peak VO₂ , local and regional indices of arterial stiffness were assessed prior to and after each period.

RESULTS

Sixty per cent of the participants were non-responders following MICT, but the incidence dropped to 20% following HIIT (P = 0.03). Absolute peak VO₂ values reached significant difference from pre-intervention (+0.38 ± 0.08 L min^-1 , P = 0.001) only when HIIT was added. Lower limb pulse wave velocity (PWV) decreased following MICT (-0.8 ± 1.1 m s^-1 , P = 0.049), whereas central PWV only decreased following HIIT (-0.8 ± 0.9 m s^-1 , P = 0.013).

CONCLUSIONS

Cardiorespiratory fitness responsiveness and reductions in PWV to a 12-month MICT period in adults with IDD improved following a period of HIIT programme inducing higher metabolic stress.

P–004 Effect of varicocelectomy on sperm DNA fragmentation rates in infertile men with clinical varicocele: a systematic review and meta-analysis

Study question

Does varicocelectomy improve sperm DNA quality in men with infertility and clinically detected varicoceles?

Summary answer

Varicocelectomy reduces sperm DNA fragmentation (SDF) rates in infertile men with clinical varicocele.

What is known already

Varicocele has been linked to male infertility through various non-mutually exclusive mechanisms, including an increase in reactive oxygen species (ROS) production that may lead to sperm DNA damage. Damage to sperm DNA may result in longer time-to-pregnancy, unexplained infertility, recurrent pregnancy loss, and failed intrauterine insemination or in vitro fertilization/intracytoplasmic sperm injection. Therefore, interventions aimed at decreasing SDF rates, including varicocele repair, have been explored to improve fertility and pregnancy outcomes potentially, either by natural conception or using medically assisted reproduction.

Study design, size, duration

Systematic review and meta-analysis

Participants/materials, setting, methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our systematic search included PubMed/Medline, EMBASE, Scielo, and Google Scholar to identify all relevant studies written in English and published from inception until October 2020. Inclusion criteria were studies comparing SDF rates before and after varicocelectomy in infertile men with clinical varicocele. Articles were included if the following SDF assays were utilized: SCSA, TUNEL, SCD test, or alkaline Comet.

Main results and the role of chance

Thirteen studies fulfilled the inclusion criteria and were selected for the analysis. The estimated weighted mean difference of SDF rates after varicocelectomy was –6.58% (13 studies, 95% CI –8.33%, –4.84%; I2=90% p < 0.0001). Subgroup analysis revealed a significant decrease in SDF rates using SCSA (eight studies, WMD –6.80%, 95% CI –9.31%, –4.28%; I2=89%, p < 0.0001), and TUNEL (three studies, WMD –4.86%, 95% CI –7.38%, –2.34%; I2=89%, p < 0.0001). The test for subgroup difference revealed that pooled results were conservative using the above SDF assays. Comet and SCD tests were used in only one study each; thus, a meta-analysis was not applicable. The studies were further categorized by the surgical technique (microsurgical versus non-microsurgical). This subgroup analysis showed a significant decrease in SDF rates using microsurgical technique (10 studies, WMD –6.70%, 95% CI –9.04%, –4.37%; I2=91%, p < 0.0001). After varicocelectomy, SDF rates were also decreased when non-microsurgical approaches were used, albeit the effect was not statistically significant (2 studies, WMD –6.84%, 95% CI –10.05%, 1.38%; I2=86%) (Figure 3). The heterogeneity was not materially affected by performing analyses by the above subgroups, suggesting that the SDF assay and surgical technique do not explain the inconsistency in the treatment effect across primary studies.

Limitations, reasons for caution

There were no randomized controlled trials comparing varicocelectomy to placebo for alleviating SDF levels. Heterogeneity was high, which may be explained by the low number of included studies. Pregnancy data are not available in most studies, thus the impact of reduced SDF after varicocelectomy on pregnancy rates unclear.

Wider implications of the findings: Our study indicates a positive association between varicocelectomy and reduced postoperative SDF rates in men with clinical varicocele and infertility, independentetly of the assays used to measure SDF. These findings may help counsel and manage infertile men with varicocele and high SDF levels.

Trial registration number

Not applicable

“I am the coronavirus”: A case report and review

Introduction

As disorders of thought, delusions are modified by patients’ background, and so their content varies widely according to location and throughout the ages. The COVID-19 pandemic has shown its global impact on society and mental health of the population, thus becoming a new delusional topic.

Objectives

We report a case where the COVID-19 pandemic has been integrated into a patient’s delusion in an attempt to raise professional awareness for this new psychotic presentation.

Methods

Review of clinical notes and literature review.

Results

A 38-year-old female patient with no prior psychiatric history presented with psychotic symptoms characterized by self-referential ideas, feelings of guilt and delusions of ruin, with a sudden onset of less than 24 hours prior to observation. The patient claimed that she was the coronavirus and, as such, she was a common topic of conversation in both television and social media, and the reported deaths caused by COVID-19 were her own doing. As a result of this, the patient was asking doctors to kill her in order to save everyone else affected by the virus. After evaluation, a diagnosis of Acute and Transient Psychotic Disorder was considered. The patient was initially treated with paliperidone, but due to hyperprolactinemia and menstrual changes this was switched to aripiprazole. Symptoms remitted fully after 21 days of treatment, and six months later no recurrences have been described.

Conclusions

This case illustrates the potential of the coronavirus pandemic outbreak as a new delusional topic. Possible side effects of treatment are also discussed.

1094 Exercise syncope as initial symptom of constrictive pericarditis in a young patient

Introduction

Constrictive pericarditis is a form of diastolic heart failure that arises because an inelastic pericardium inhibits cardiac filling. Syncope is a rare initial symptom of constrictive pericarditis.

Clinical case

A 22-year-old man with previous medical history of viral meningitis when he was 3 months-old but without any family history of cardiac disease or sudden cardiac death, was admitted to the Emergency Department for syncope. During the last year, he had suffered several episodes of intense exercise-related syncope. The patient denied having prodromes, chest pain, palpitations or any other symptoms. The physical exam of the patient was normal with stable vital signs. Normal S1 and S2 heart sounds were present, no murmurs or gallop. There were no signs of heart failure, only a minimal jugular ingurgitation. An electrocardiogram (ECG) revealed sinus rhythm, signs of bi-atrial enlargement (prominent P-wave with P mitral morphology in DI-II leads, with enhanced negative deflection in V1), and negative asymmetric T-waves in inferior (DII-III-aVF) and V6 leads. Chest X-ray showed minimal calcium density in the inferior pericardial silhouette. The patient was admitted in the Cardiology Department for aetiological study. A transthoracic echocardiogram revealed a marked protodiastolic cleft in the interventricular septum, with 40% variations of the transmitral flow with the respiratory changes and dilation of the cava vein, with absent respiratory collapse. A marked thickening and calcification of the inferoposterior pericardium was also seen. Considering these results, the diagnosis of constrictive pericarditis was suggested (Fig. A, B, C). Blood tests for autoimmune disease screening, as well as infectious diseases, including Quantiferon test, HIV, HVC, HVB and other viral serologies were done, with negative results. A cardiac magnetic resonance was requested, which confirmed the echocardiographic findings, with bi-atrial enlargement and markedly thickened pericardium with loss of signal, suggestive of calcification. Left and right ventricle had normal dimensions and contractility. The CT coronary angiography revealed normal coronary anatomy. Extensive calcification and pericardial thickening were shown, with myocardial infiltration in the lateral-basal area (Fig D). It was considered important to rule out any additional arrhythmic aetiology of the exercise syncope. Therefore, a stress test and, an electrophysiologic study were done, both with normal results. The patient remained asymptomatic and a pericardiectomy was indicated given the severe thickening and calcification of the pericardium and frequent syncopal episodes that our patient suffered.

Conclusions

Syncope as the initial symptom in the absence of significant right heart failure signs is a very unusual form of presentation of idiopathic constrictive pericarditis given the severe thickening and calcification of the pericardium of our patient.

Abstract 1094 Figure.

Does freeze-all policy affect IVF outcome in poor ovarian responders?

OBJECTIVE

To evaluate whether the freeze-all strategy affects in-vitro fertilization (IVF) outcome in poor ovarian responders (POR) defined according to the Bologna criteria.

METHOD

This was a retrospective cohort study of patients undergoing IVF treatment between January 2012 and December 2016 at a single center. A total of 433 POR (as defined by the Bologna criteria) fulfilled criteria and were included in the study; of these, 277 patients underwent fresh embryo transfer (ET) and 156 followed the freeze-all policy. All patients underwent controlled ovarian stimulation (COS) following a gonadotropin-releasing hormone antagonist protocol, and cleavage-stage ET. Main outcome measure was ongoing pregnancy rate. Secondary outcomes included implantation and clinical pregnancy rates. The freeze-all strategy was implemented when the progesterone serum level was > 1.5 ng/mL or the endometrium was < 7 mm on the trigger day, or as per patient preference. Patients with previous failed fresh ET also underwent fresh ET or freeze-all strategy considering the indications mentioned above.

RESULTS

Mean maternal age in the freeze-all group was 39.5 ± 3.6 years and in the fresh ET group was 39.7 ± 3.8 years (P = 0.54). Mean number of embryos transferred (nET) was 1.53 ± 0.6 and 1.60 ± 0.6 (P = 0.12) in the freeze-all and fresh ET groups, respectively. Ongoing pregnancy rate did not differ significantly between the freeze-all and fresh ET groups (9.6% vs 10.1%, respectively; relative risk (RR), 0.95; 95% CI, 0.52-1.73), nor did the clinical pregnancy rate (14.1% vs 13.7%, respectively; RR, 1.03; 95% CI, 0.63-1.67). Implantation rate was 9.6% and 9.8% (P = 0.82) in the freeze-all and fresh ET groups, respectively. Logistic regression analysis (including maternal age, antral follicle count, number of retrieved and mature oocytes, nET, and fresh ET vs freeze-all strategy) indicated that maternal age (P < 0.001) and nET (P = 0.039) were the only independent variables associated with ongoing pregnancy rate.

CONCLUSIONS

The freeze-all strategy, compared with fresh ET, had no impact on IVF outcomes in POR patients as defined according to the Bologna criteria. Multicenter studies including large numbers of patients should be carried out to confirm the results of this study and reach conclusions about the potential benefits of the freeze-all policy for poor responders. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Economic analysis of CDC's culture- and smear-based tuberculosis instructions for Filipino immigrants

SETTING

In 2007, the US Centers for Disease Control and Prevention (CDC) revised its tuberculosis (TB) technical instructions for panel physicians who administer mandatory medical examinations among US-bound immigrants. Many US-bound immigrants come from the Philippines, a high TB prevalence country.

OBJECTIVE

To quantify economic and health impacts of smear- vs. culture-based TB screening.

DESIGN

Decision tree modeling was used to compare three Filipino screening programs: 1) no screening, 2) smear-based screening, and 3) culture-based screening. The model incorporated pre-departure TB screening results from Filipino panel physicians and CDC databases with post-arrival follow-up outcomes. Costs (2013 $US) were examined from societal, immigrant, US Public Health Department and hospitalization perspectives.

RESULTS

With no screening, an annual cohort of 35 722 Filipino immigrants would include an estimated 450 TB patients with 264 hospitalizations, at a societal cost of US$9.90 million. Culture-based vs. smear-based screening would result in fewer imported cases (80.9 vs. 310.5), hospitalizations (19.7 vs. 68.1), and treatment costs (US$1.57 million vs. US$4.28 million). Societal screening costs, including US follow-up, were greater for culture-based screening (US$5.98 million) than for smear-based screening (US$3.38 million). Culture-based screening requirements increased immigrant costs by 61% (US$1.7 million), but reduced costs for the US Public Health Department (22%, US$750 000) and of hospitalization (70%, US$1 020 000).

CONCLUSION

Culture-based screening reduced imported TB and US costs among Filipino immigrants.

Gonadotropin-releasing hormone agonists for ovarian protection during cancer chemotherapy: systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of gonadotropin-releasing hormone agonist (GnRHa) administration before and/or during cancer chemotherapy for the protection of ovarian reserve in premenopausal women without prior diagnosis of infertility.

METHODS

This was a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing administration of GnRHa before and/or during chemotherapy vs chemotherapy alone. Eligible participants were premenopausal women at any stage of cancer, without previous diagnosis of infertility. An electronic database search in MEDLINE, CENTRAL, LILACS and ClinicalTrials.gov was performed. After selecting eligible studies, the relative risk (RR) was assessed for primary ovarian insufficiency (POI)/amenorrhea and for spontaneous pregnancy after completion of treatment.

RESULTS

Thirteen RCTs comparing concurrent use of GnRHa and chemotherapy (609 participants) with chemotherapy alone (599 participants) were eligible for meta-analysis. All trials were open-label and patients had been treated for breast cancer (n = 1099) or lymphoma (n = 109). GnRHa had a significant benefit on the risk of POI/amenorrhea (RR, 0.60; 95% CI, 0.45-0.79), which persisted in subgroup analysis for breast cancer (RR, 0.57; 95% CI, 0.43-0.77) but not for lymphoma patients (RR, 0.70; 95% CI, 0.20-2.47). The rate of spontaneous pregnancy after completion of treatment was higher in women receiving GnRHa plus chemotherapy compared with those receiving chemotherapy alone (RR, 1.43; 95% CI, 1.01-2.02). Overall, the quality of evidence was low due to the unclear risk of bias, short follow-up and lack of objective assessment of ovarian function and reserve.

CONCLUSIONS

Evidence, albeit of low quality, supports the use of GnRHa before and/or during chemotherapy to reduce the risk of POI and increase the probability of spontaneous pregnancy in the short term. Further high quality RCTs with more accurate assessment of ovarian reserve are needed to support definitive recommendations for clinical practice. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Psychiatric Symptomatology as the Initial Presentation of Brain Cancer

Glioblastoma multiforme is the most common primary adult brain tumor. Clinically, non-specific psychiatric symptoms may arise as their first and only manifestation, prior to any neurological deficits. The most form of psychiatric presentation of neurological diseases are depressive complaints, although these may also be accompanied by behavioral and/or cognitive, anxious and psychotic symptoms. By explaining this case report we aim to emphasize the importance of considering the diagnosis of an organic brain disease, even when only primary psychiatric symptoms are evident. The bibliographic research was made using PubMed and Scielo, and analysis of the electronic patient process. Man of 68 years with a history of hypertension, nephrectomy, splenectomy and left brachial plegia after a car accident. He had been previously seen by a psychiatrist for a 6-month history of depressive symptoms, which had been successfully treated. He later developed new behavioral changes such as heteroaggressiveness, social maladjustment and disfasia, for which he was sent to the emergency room. Brain-CT scan displayed a left front temporal expansive injury. Admitted to the Neurology Department for further diagnostic investigation. Subsequent MRI, detected massive infiltrative lesion with significant mass effect and cystic/necrotic area. The anatomopathology disclosed a glioblastoma grade IV. This case reinforces the importance of carrying a imagiologic workup in cases like this, especially on patients with atypical presentation of psychiatric symptoms.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Zoophilia in a Patient with Parkinson's Disease

Introduction

Parkinson's disease (PD) is a neurodegenerative brain disorder characterized by Bradykinesia, muscle rigidity and resting tremor. Non-motor symptoms like neuropsychiatric manifestations can also cause significant morbidity. Common medications used in anti-Parkinsonian treatment such as dopaminergic agonists, may help motor symptoms but can also cause or contribute to adverse behavioral manifestations. These include dementia, depression, anxiety, insomnia, psychosis and paraphilic disorders. There are sporadic reports of zoophilia in association with dopaminergic therapy.

Objectives

Report of a clinical case of PD and zoophilia.

Aims

clinicians must be aware of paraphilic disorders, namely zoophilia, in patients with dopaminergic medication.

Method

Search of the Pubmed database was conducted for articles published that had “zoophilia [All Fields] and Parkinson [All Fields]”, resulting in 3 eligible articles through October 2016. The patient's clinical records were also reviewed.

Case Report

A 77-year-old man, living in a rural area and with a low educational background, with akinetic–rigid PD in an advanced stage and followed by neurology since 2003. His family physician sent him to a psychiatric assessment for hyper-sexuality with zoophilia. The psychiatrist found that these behaviors had begun a week after levodopa was increased along with the introduction of selegiline. The psychiatrist has introduced quetiapine with significant decrease of the hyper-sexuality and the end of zoophilic episodes.

Conclusion

Despite hyper-sexuality is found in just 2–6% of PD patients in connection with dopaminergic treatment. This case report emphasizes how crucial it is to evaluate PD patients’ sexuality as well as to explain these adverse effects to the families involved.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Chemobrain and Anxiety in a Patient with Hodgkin's Lymphoma: Case Report and Literature Discussion

Impaired cognitive function is a common complaint among oncologic patients. Chemotherapy-induced cognitive impairment (CICI), also called “chemobrain” or “chemofog” is currently recognized as a relatively common adverse effect of chemotherapeutic agents and is defined as the impairment of patients’ memory, learning, concentration, reasoning, executive function, attention, and visuospatial skills during and after discontinuation of chemotherapy. In particular, it is apparent that a subset of chemotherapy-treated haematological malignancy survivors experience cognitive impairment. On the other hand, the emotional distress associated with the disclosure of cancer diagnosis and/or the administration of chemotherapy represents a strong reason for psychosomatic manifestations in patients with cancer. The authors report a case of a patient with Hodgkin's lymphoma, cognitive impairment and symptoms of anxiety and they propose to discuss the controversies around the factors implicated on cognitive impairment in oncological patients.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Intracytoplasmic sperm injection outcomes with cryopreserved testicular sperm aspiration samples

Intracytoplasmic sperm injection (ICSI) may be performed with testicular frozen-thawed spermatozoa in patients with nonobstructive azoospermia (NOA). Sperm retrieval can be performed in advance of oocyte aspiration, as it may avoid the possibility of no recovery of spermatozoa on the day of oocyte pickup. There are few studies available in the literature concerning the use of frozen-thawed spermatozoa obtained from testicular sperm aspiration (TESA). To evaluate the effects and the outcomes of ICSI with frozen-thawed spermatozoa obtained by TESA, we performed a retrospective analysis of 43 ICSI cycles using frozen-thawed TESA. We obtained acceptable results with a fertilisation rate of 67.9%, an implantation rate (IR) of 17.1%, and clinical and ongoing pregnancy rates of 41.9% and 37.2% respectively. The results of this study suggest that performing ICSI using cryopreserved frozen-thawed testicular spermatozoa with TESA as a first option is a viable, safe, economic and effective method for patients with NOA.

The genetic basis and experimental evolution of inbreeding depression in Caenorhabditis elegans

Determining the genetic basis of inbreeding depression is important for understanding the role of selection in the evolution of mixed breeding systems. Here, we investigate how androdioecy (a breeding system characterized by partial selfing and outcrossing) and dioecy (characterized by obligatory outcrossing) influence the experimental evolution of inbreeding depression in Caenorhabditis elegans. We derived inbred lines from ancestral and evolved populations and found that the dioecious lineages underwent more extinction than androdioecious lineages. For both breeding systems, however, there was selection during inbreeding because the diversity patterns of 337 single-nucleotide polymorphisms (SNPs) among surviving inbred lines deviated from neutral expectations. In parallel, we also followed the evolution of embryo to adult viability, which revealed similar starting levels of inbreeding depression in both breeding systems, but also outbreeding depression. Under androdioecy, diversity at a neutral subset of 134 SNPs correlated well with the viability trajectories, showing that the population genetic structure imposed by partial selfing affected the opportunity for different forms of selection. Our findings suggest that the interplay between the disruptions of coevolved sets of loci by outcrossing, the efficient purging of deleterious recessive alleles with selfing and overdominant selection with outcrossing can help explain mixed breeding systems.

Children of Bacchus - withdrawal in the ER

Through the ages, Portugal's History, geography, industry and mysticism are intertwined with viniculture. Legends proclaim Lusus the founding father of its inhabitants, who answer to this day to the designation of "Lusos". Lusus was said to be a companion of Bacchus, the Roman God of Wine. Portugal was the 7th major alcohol consumer, according to data by the world Drink Trends 2005. Facing these numbers, it is fairly understood the morbidity and lethality potential of multi-organic diseases, neurologic entities, accidents, suicides, and familial disfunction. Alcoholic Delirium may be caused by alcohol withdrawal, or by a sudden increase in consumption, or phenomena where tolerance to alcohol is diminished. These complex states are affluent in symptomatology, which can evolve to critical life threatening stages.

Objective:

The authors’ aim is to present a clinical case of Delirium by alcoholic withdrawal.

Methods:

The authors undertake a revision of this topic in the literature and clinical files review.

Conclusions:

Delirium is not uncommon in Portuguese emergency rooms, though often misdiagnosed. The knowledge tools should be shared by other specialities besides Psychiatry or Liaison Mental Health for treatment may be life-saving. After crisis, the treatment should proceed, based on maintaining abstinence by medication and therapy.

Psychiatric Development in Huntington Disease

Huntington Disease (HD) is an untreatable condition with an hereditary basis, autosomal dominant, progressive and Neurodegenerative, with average beginning age in-between 35 and 44 years old. Choreic movements are the major feature of this disease, but the most precocious symptoms are psychiatric alterations. Studies reveal depression numbers to be double than those found in the general population, with disturbing numbers in suicide attempts. Behavioural alterations (psychotic symptoms, agitation, irritability, and insomnia) may become severe in long-term course.

Objective:

The authors’ aim is to approach the different psychiatric manifestations in HD, and Psychiatry's role in afflicted families.

Methods:

The authors undertake a revision of this topic in the literature.

Conclusion:

Familiar history is underestimated, and in the course of the disease, antidepressive treatments are underutilized. Atypical antipsychotic with minimal extrapyramidal side effects are welcome on motor as well as behavioural symptoms. Family counselling and psychological support is key.

Increased p53 gene dosage reduces neointimal thickening induced by mechanical injury but has no effect on native atherosclerosis

OBJECTIVE

The tumor suppressor p53 regulates cell proliferation and apoptosis, two key processes in the pathogenesis of occlusive vascular disease. Here, we examined the consequences of heightening p53 function on neointimal lesion formation in the setting of atherosclerosis and mechanical injury.

METHODS

For this study we employed immunohistopathological characterization of neointimal lesions in atherosclerosis-prone apolipoprotein E-null mice with normal p53 gene dosage (apoE-KO) and carrying a p53 transgene (Super-p53/apoE-KO). We also carried out molecular studies in macrophages and smooth muscle cells (SMCs) obtained from these mice.

RESULTS

The p53 transgene conferred p53 gain-of-function in cultured cells and mice. In vitro, survival of irradiated Super-p53 macrophages and femoral SMCs was reduced, but only Super-p53 SMCs exhibited attenuated proliferation. In vivo, whereas the size of spontaneously formed and diet-induced aortic atheromas was indistinguishable in apoE-KO and Super-p53/apoE-KO mice, the latter exhibited attenuated neointimal thickening in mechanically injured femoral artery. In both models, neither apoptosis nor cell proliferation were affected by additional p53 gene dosage when examined in established neointimal lesions. However, at 2 days after mechanical injury when neointimal lesions were not yet formed, cell proliferation was significantly attenuated within medial SMCs of Super-p53/apoE-KO mice.

CONCLUSION

Heightening p53 function has differential effects on in vitro proliferation of macrophages (unaffected) versus SMCs (reduced), and on native atherosclerosis (unaffected) versus mechanically induced neointimal thickening (reduced) in apoE-KO mice. The protective effect of p53 in mechanically injured femoral artery coincided with limited medial SMC proliferation at early time points preceding neointima formation, but neither medial nor neointimal cell proliferation was affected in vessels with established occlusive lesions. These findings corroborate p53 gain-of-function as a promising therapeutic strategy to limit post-angioplasty restenosis but not native atherosclerosis.

Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old

BACKGROUND

Acute bronchiolitis is the leading cause of medical emergencies during winter in children younger than two years of age. Chest physiotherapy is thought to assist infants in the clearance of secretions and to decrease ventilatory effort.

OBJECTIVES

To determine the efficacy and safety of chest physiotherapy in infants aged less than 24 months old with acute bronchiolitis.

SEARCH STRATEGY

In June 2006 we updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006); MEDLINE (2004 to May Week 4 2006); EMBASE (July 2004 to December 2005) and CINAHL (1982 to May Week 4 2006).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which chest physiotherapy was compared against no intervention or against another type of physiotherapy in paediatric patients younger than 24 months old.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data. The primary outcome was a severity clinical score. Secondary outcomes were length of hospital stay, duration of oxygen supplementation, and the use of bronchodilators and steroids.

MAIN RESULTS

Three clinical trials met the inclusion criteria. All evaluated vibration and percussion techniques with children in postural drainage positions compared to no intervention. The study populations were hospitalised infants with a clinical diagnosis of acute bronchiolitis, although one study included only infants who required nasogastric tube feeding or intravenous fluids. None of the other included trails observed any differences in the severity of the clinical score at day five, during each of the five days of the trial, or until discharge; length of hospital stay; or oxygen requirements between paediatric patients receiving chest physiotherapy and control.

AUTHORS' CONCLUSIONS

Based on the results of three RCTs, chest physiotherapy using vibration and percussion techniques does not reduce length of hospital stay, oxygen requirements, or improve the severity clinical score in infants with acute bronchiolitis. These were infants who were not on mechanical ventilation and who did not have any other co-morbidity. Chest physiotherapy using forced expiratory techniques needs to be further evaluated by clinical research.

Dehydroleucodine inhibits vascular smooth muscle cell proliferation in G2 phase

Vascular smooth muscle cell (VSMC) proliferation plays an important role in the development of atherosclerosis and in the vascular changes seen in hypertension. Dehydroleucodine (DhL) is a sesquiterpene lactone that inhibits cell proliferation in plant cells. In this paper, we study the effect of DhL in the proliferation of VSMCs stimulated with 10% fetal bovine serum (FBS). Very low concentrations of DhL (2-6 microM) inhibited VSMC proliferation and induced cell accumulation in G2. DhL did not affect the dynamics of 3H-thymidine incorporation, and did not modify either the activity of DNA polymerase or the incorporation of deoxyribonucleotides in an in vitro assay. Moreover, DhL did not induce apoptosis in VSMCs. These results indicate that DhL, in very low concentration, induces a transient arrest of VSMCs in G2. Our data show that VSMCs are especially sensitive to DhL effect, suggesting that DhL could be potentially useful to prevent the vascular pathological changes seen in hypertension and other vascular diseases.

Metformin monotherapy for type 2 diabetes mellitus

BACKGROUND

Metformin is an anti-hyperglycaemic agent used for the treatment of type 2 diabetes mellitus. Type 2 diabetes may present long-term complications: micro- (retinopathy, nephropathy and neuropathy) and macrovascular (stroke, myocardial infarction and peripheral vascular disease). Two meta-analyses have been published before, although only secondary outcomes were assessed.

OBJECTIVES

To assess the effects of metformin monotherapy on mortality, morbidity, quality of life, glycaemic control, body weight, lipid levels, blood pressure, insulinaemia, and albuminuria in patients with type 2 diabetes mellitus.

SEARCH STRATEGY

Studies were obtained from computerised searches of multiple electronic databases and hand searches of reference lists of relevant trials identified. Date of last search: September 2003.

SELECTION CRITERIA

Trials fulfilling the following inclusion criteria: Diabetes mellitus type 2, metformin versus any other oral intervention, assessment of relevant clinical outcome measures, use of random allocation.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data, using a standard data extraction form. Data were summarised under a random effects model. Dichotomous data were expressed as relative risk. We calculated the risk difference (RD), and the Number Needed to Treat, when it was possible. We collected data of mean and standard deviation from changes to baseline. However many trials reported end point data. This limitation lead to the expression of the results as standardised mean differences (SMD) and an overall SMD was calculated. Heterogeneity was tested for using the Z score and the I-squared statistic. Subgroup, sensitivity analysis and meta-regression were used to explore heterogeneity.

MAIN RESULTS

We included for analysis 29 trials with 37 arms (5259 participants), comparing metformin (37 arms and 2007 participants) with sulphonylureas (13 and 1167), placebo (12 and 702), diet (three and 493), thiazolidinediones (three and 132), insulin (two and 439), meglitinides (two and 208), and glucosidase inhibitors (two and 111). Nine studies reported data on primary outcomes. Obese patients allocated to intensive blood glucose control with metformin showed a greater benefit than chlorpropamide, glibenclamide, or insulin for any diabetes-related outcomes (P = 0.009), and for all-cause mortality (P = 0.03). Obese participants assigned to intensive blood glucose control with metformin showed a greater benefit than overweight patients on conventional treatment for any diabetes-related outcomes (P = 0.004), diabetes-related death (P = 0.03), all-cause mortality (P = 0.01), and myocardial infarction (P = 0.02). Patients assigned to metformin monotherapy showed a significant benefit for glycaemia control, weight, dyslipidaemia, and diastolic blood pressure. Metformin presents a strong benefit for HbA1c when compared with placebo and diet; and a moderated benefit for: glycaemia control, LDL cholesterol, and BMI or weight when compared with sulphonylureas.

AUTHORS' CONCLUSIONS

Metformin may be the first therapeutic option in the diabetes mellitus type 2 with overweight or obesity, as it may prevent some vascular complications, and mortality. Metformin produces beneficial changes in glycaemia control, and moderated in weight, lipids, insulinaemia and diastolic blood pressure. Sulphonylureas, alpha-glucosidase inhibitors, thiazolidinediones, meglitinides, insulin, and diet fail to show more benefit for glycaemia control, body weight, or lipids, than metformin.

Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old

BACKGROUND

Acute bronchiolitis is the leading causes of medical emergencies during winter in children younger than two years of age. Chest physiotherapy is thought to assist infants in the clearance of secretions and decrease ventilatory effort.

OBJECTIVES

To determine the efficacy and safety of chest physiotherapy in infants aged less than 24 months old with acute bronchiolitis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2004) which contains the Acute Respiratory Infection Group's specialised register; MEDLINE (January 1966 to June 2004); EMBASE (1990 to June 2004); PASCAL; SCISEARCH; LILACS; and Cumulative Index to the Nursing & Allied Health Literature (CINAHL) (1982 to May 2004).

SELECTION CRITERIA

Randomised controlled trails (RCTs) in paediatric patients younger than twenty four months old in which chest physiotherapy was compared against no intervention or against another type of physiotherapy.

DATA COLLECTION AND ANALYSIS

Two independent reviewers extracted the data. Primary outcome was a severity clinical score. Secondary outcomes were length of hospital stay, duration of oxygen supplementation, and the use of bronchodilators and steroids.

MAIN RESULTS

Three clinical trials met the inclusion criteria. All evaluated vibration and percussion techniques in postural drainage positions compared to no intervention. The study population were hospitalised infants with a clinical diagnosis of acute bronchiolitis, although one study included only infants who required nasogastric tube feeding or intravenous fluids. None of the other included trails observed any differences in the severity of the clinical score at day five or during each of the five days of the trial or until discharge, length of hospital stay, or oxygen requirements between chest physiotherapy group and control.

AUTHORS' CONCLUSIONS

Based on the results of three RCTs, chest physiotherapy using vibration and percussion techniques does not reduce length of hospital stay, oxygen requirements, or improve the severity clinical score in infants with acute bronchiolitis that are not under mechanical ventilation, and who do not have any other co-morbidity. Chest physiotherapy using forced expiratory technique needs to be evaluated by clinical research.

Haloperidol dose for the acute phase of schizophrenia

BACKGROUND

Haloperidol is a benchmark, accessible antipsychotic against which the effects of newer treatments are gauged.

OBJECTIVES

The primary goal of this review is to determine the best range of doses for haloperidol for the treatment of people acutely ill with schizophrenia.

SEARCH STRATEGY

The reviewers searched Biological Abstracts (1980-1999), CINAHL (1982-1999), The Cochrane Library (1999, Issue 2), The Cochrane Schizophrenia Group's Register (December 1999), EMBASE (1980-1999), MEDLINE (1966-1999) and PsycLIT (1887-1999). They also inspected all references of all identified trials and included studies sought as a citation on SCISEARCH database (1980-1999). Authors of identified studies and pharmaceutical companies were also contacted.

SELECTION CRITERIA

Studies were selected if they involved people being treated for acute schizophrenia, randomised to two or more dose ranges of non-depot haloperidol, and if they reported clinically meaningful outcomes.

DATA COLLECTION AND ANALYSIS

The reviewers independently and blindly inspected citations (10% reliability check), they ordered papers, and reliably re-inspected and quality assessed the full reports. The reviewers, again working independently, also extracted data. For homogeneous dichotomous data the relative risk (RR), 95% confidence intervals (CI) were calculated on an intention-to-treat basis. Reviewers assumed that people who left the study early or were lost to follow-up had a negative outcome. Weighted mean differences (WMD) were calculated for continuous outcomes that reported intention to treat (ITT), last observation carried forward (LOCF) data. Data was excluded if loss to follow-up was greater than 50%.

MAIN RESULTS

Sixteen trials with nineteen different randomised dose comparisons were included. No studies reported data on relapse rates, quality of life and none compared >1.5-3.0 mg/day haloperidol to higher dose ranges. Using low doses (>3-7.5mg/day) did not clearly result in loss of efficacy (no clinically important improvement in global state, versus >7.5-15mg/day n=48, 1 RCT, RR 1.09 CI 0.7 to 1.8; versus >15-35mg/day n=81, 2 RCTs, 0.95 CI 0.8 to 1.2). Doses of haloperidol in the range of >3-7.5 mg/day had a lower rate of development of clinically significant extrapyramidal adverse effects than higher doses (clinically significant extrapyramidal adverse effects, versus >7.5-15mg/day n=64, 2 RCTs, RR 0.12 CI 0.01 to 2.1; versus >15-35mg/day n=144, 3 RCTs RR 0.59 CI 0.5 to 0.8, NNH 3 CI 2 to 6; versus >35mg/day n=86, 2 RCTs, RR 0.70 CI 0.5 to 1.1). All other comparisons between dose ranges did not yield statistically significant differences, but several, particularly with lower dose ranges, were underpowered to detect clinically meaningful differences.

REVIEWER'S CONCLUSIONS

No results are conclusive and all are based on small, short, studies. It would be understandable, however, if clinicians were cautious in prescribing doses in excess of 7.5 mg/day of haloperidol to a person with uncomplicated acute schizophrenia, and if people with schizophrenia were equally reticent to take greater doses. Further research is needed regarding the efficacy and tolerability of the >1.5-3.0 mg/day dose range.

[Multiparametric analysis for the diagnosis of iron deficiency anemia]

The serum transferrin receptor (sTR) as a marker of iron depletion was evaluated in two groups: 50 normal adults of both sexes living at sea level and 50 iron deficiency anemias (secondary to nutritional, gastrointestinal or gynecologic diseases). Mean values were 16.6 nmol/L (interval of reference 8.8 to 26.2), for controls, without variations related to age and sex, and 66.3 nmol/L (16.1 to 148.8) for anemic patients. Statistical analysis (receiver operating characteristics, ROC) determined an optimal reference interval of 8.8 to 25.8 nmol/L. Predictive values as a diagnostic tool were 97.5%, PV (+) and 97.7%, PV (-); diagnostic efficiency was 97.7%. In both controls and anemics it was observed: 1) an inverse relationship between sTR and serum ferritin (F) (r2 72%; p < 0.001); 2) wide variations of sTR when plasma hemoglobin (Hb) was < 100 g/L (r2 71%; p < 0.001); 3) values for the sTR/logarithm of serum ferritin ratio (sTR/F index) much higher in anemics (75.8) than in controls (9.6). In the former group, iron supplementation normalized sTR levels but did not change ferritin values. We conclude that sTR is a specific and sensitive index of functional iron deficiency and therefore a quick, accurate and non invasive quantitative parameter for the diagnosis of iron deficient erythropoiesis.

Modulation of apoptosis, proliferation, and p27 expression in a porcine coronary angioplasty model

Smooth muscle cell (SMC) proliferation is a prominent feature of intimal hyperplasia after percutaneous coronary interventions. p27 is a critical regulator of cell proliferation. Our aims were to analyze the time course of p27 expression, Ki67 proliferative index, and apoptosis after angioplasty in the porcine coronary artery. We also investigated the effects of rapamycin--an antiproliferative drug--on these events. The expression of p27 and Ki67, and apoptosis were determined in porcine coronary arteries harvested at timed intervals from 1 h to 28 days after angioplasty. A gradual increase in p27 expression was observed from 7 to 28 days. Ki67 expression peaked by 7-14 days after angioplasty. By 21-28 days, Ki67 expression decreased, while p27 reached maximal levels. An early apoptotic response was found by 6 h, followed by a gradual return to baseline. Rapamycin induced a reduction in Ki67 proliferative index (2 +/- 0.5%) and an increase in apoptosis (7 +/- 1%) versus untreated animals at the 28-day time point (5 +/- 1 and 1 +/- 0.5%, respectively; P < 0.05). In summary, coronary angioplasty induced a rapid apoptotic response, followed by a progressive increase in proliferation. Later on, as p27 expression increased in the vessel wall, cell proliferation decreased. Modulation of cell cycle progression may be a useful therapeutic approach in the treatment of intimal hyperplasia after angioplasty.