Intraovarian platelet-rich plasma injection and IVF outcomes in patients with poor ovarian response: a double-blind randomized controlled trial

STUDY QUESTION

Does platelet-rich plasma (PRP) intraovarian injection increase the number of retrieved oocytes in successive ovarian punctions among patients with poor ovarian reserve (POR)?

SUMMARY ANSWER

The injection of PRP increases the number of retrieved oocytes without increasing the quality of developed blastocysts.

WHAT IS KNOWN ALREADY

Management of women with reduced ovarian response to stimulation is one of the significant challenges in reproductive medicine. Recently, PRP treatment has been proposed as an adjunct in assisted reproduction technology, with controversial results.

STUDY DESIGN, SIZE, DURATION

This placebo-controlled, double-blind, randomized trial included 60 patients with POR stratified according to the POSEIDON classification groups 3 and 4. It was conducted to explore the efficacy and safety of intraovarian PRP injection. Patients were proposed to undergo three consecutive ovarian stimulations to accumulate oocytes and were randomized to receive either PRP or placebo during their first oocyte retrieval. Randomization was performed using computer-generated randomization codes. Double blinding was ensured so that neither the participant nor the investigators knew of the treatment allotted. All patients underwent three ovarian stimulations and egg retrieval procedures. ICSI was performed after a third ovarian puncture. The primary endpoint was the number of mature oocytes retrieved after PRP or placebo injection in successive ovarian punctures.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Sixty women (30-42 years) fulfilling inclusion criteria were randomized in equal proportions to the treatment or control groups.

MAIN RESULTS AND THE ROLE OF CHANCE

The baseline demographic and clinical characteristics [age, BMI, anti-Müllerian hormone (AMH) levels] were comparable between the groups. Regarding the primary endpoint, the cumulative number (mean ± SEM) of retrieved mature oocytes was slightly higher in the treatment group: 10.45 ± 0.41 versus 8.91 ± 0.39 in the control group, respectively (95% CI of the difference 0.42-2.66; P = 0,008). The number of mature oocytes obtained among all patients increased in successive egg retrievals: 2.61 ± 0.33 (mean ± SEM) in punction 1 (P1), 3.85 ± 0.42 in P2, and 4.73 ± 0.44 in P3. However, the increase was higher among patients receiving the assessed PRP treatment. In P2, the number of retrieved mature oocytes was 4.18 ± 0.58 versus 3.27 ± 0.61 in controls (95% CI of the difference: -0.30 to 2.12; P = 0.138) and in P3, 5.27 ± 0.73 versus 4.15 ± 0.45 (95% CI of the difference: 0.12-2.12; P = 0.029). The mean ± SEM number of developed and biopsied blastocysts was 2.43 ± 0.60 in the control group and 1.90 ± 0.32 in the treatment group, respectively (P = 0.449). The mean number of euploid blastocysts was 0.81 ± 0.24 and 0.81 ± 0.25 in the control and treatment groups, respectively (P = 1.000). The percentages of patients with euploid blastocysts were 53.33% (16 out of 30) and 43.33% (13 out of 30) for patients in the control and treatment groups, respectively (Fisher's exact test P = 0.606). The overall pregnancy rate per ITT was 43% (26 out of 60 patients). However, the percentage of clinical pregnancies was higher in the control group (18 out of 30, 60%) than in the treatment group (8 out of 30, 27%) (P = 0.018). There was also a trend toward poorer outcomes in the treatment group when considering full-term pregnancies (P = 0.170). There were no differences between control and treatment groups regarding type of delivery, and sex of newborns.

LIMITATIONS, REASONS FOR CAUTION

The mechanism of the potential beneficial effect of PRP injection on the number of retrieved oocytes is unknown. Either delivered platelet factors or a mechanical effect could be implicated. Further studies will be needed to confirm or refute the data presented in this trial and to specify the exact mechanism of action, if any, of PRP preparations.

WIDER IMPLICATIONS OF THE FINDINGS

The increasing number of women with a poor response to ovarian stimulation supports the exploration of new areas of research to know the potential benefits of therapies capable of increasing the number of oocytes available for fertilization and improving the quality of developed blastocysts. An increase in the retrieved oocytes in both arms of the trial suggests that, beyond the release of growth factor from platelets, a mechanical effect can play a role. However, neither improvement in euploid blastocyst development nor pregnancy rates have been demonstrated.

STUDY FUNDING/COMPETING INTEREST(S)

This trial was supported by Basque Government and included in HAZITEK program, framed in the new Euskadi 2030 Science and Technology Plan (PCTI 2030). These aids are co-financed by the European Regional Development Fund (FEDER). The study funders had no role in the study design, implementation, analysis, manuscript preparation, or decision to submit this article for publication. No competing interests are declared by all the authors.

TRIAL REGISTRATION NUMBER

Clinical Trial Number EudraCT 2020-000247-32.

TRIAL REGISTRATION DATE

3 November 2020.

DATE OF FIRST PATIENT’S ENROLLMENT

16 January 2021.

POS0464 DIFFERENTIAL MOLECULAR PROFILES IN THE SYNOVIAL TISSUE AND SYNOVIAL FLUID OF PATIENTS WITH RHEUMATOID ARTHRITIS AND PSORIATIC ARTHRITIS

Background

The differential diagnosis of Rheumatoid Arthritis (RA) and Psoriatic arthritis (PsA) is often difficult due to the similarity of symptoms and the unavailability of reliable clinical biomarkers. Molecular alterations have been suggested to contribute to the pathophysiological processes in the knee joint, and it is known that chronic inflammation induces significant changes in the synovial tissue (ST) and synovial fluid (SF) lipidome and proteome.

Objectives

We aimed to evaluate whether specific characteristics in the molecular profiles from ST and SF could support the differential diagnosis of these diseases.

Methods

ST frozen samples of patients affected by RA (n=6), PsA (n=12) and control donors (n=10) were compared using Matrix-Assisted Laser Desorption Ionization Mass Spectrometry Imaging (MALDI-MSI) for spatially resolved lipid analysis. To this end, tissue sections were measured on a RapifleX MALDI-TOF/TOF instrument. Next, a targeted approach based on multiple reaction monitoring (MRM-MS) was performed to further validate the lipidomic alterations reported by MALDI-MSI between RA and PsA tissues. In this case, lipids extracted from SF (control donors (n=4), RA (n=21) and PsA (n=27)) were analyzed in a QTRAP 4000 mass spectrometer for the targeted analysis of 84 lipid species. Finally, a quantitative proteomic analysis was carried out on FFPE ST from RA (n=13), PsA (n=13) and controls (n=8) by nLC-MS/MS analysis using a TimsTOF Pro system (Bruker). Statistical analyses were performed using GraphPad Prism, Metaboanalyst and Perseus software.

Results

Lipid profiles in ST from PsA and RA were unequivocally distinguished by MALDI-MSI followed by PCA-DA, and were also different comparing with control tissues. Interestingly, several lipid species, including sphingomyelins, phosphatidylcholines (PC) and phosphatidylethanolamines (PE), presented the greatest separation power to classify RA and PsA tissue samples. ANOVA analysis found 35 lipid species significantly different among the study groups, most of them significantly increased in RA and PsA compared to controls. Particularly, 11 lipids showed higher levels in PsA tissues compared with RA, including several PC and PE. The spatial distribution of these PE species was associated with areas of the sublining layer with increased vascularity and inflammatory cell infiltrates, according to MALDI-MSI images. On the other hand, RA and PsA patients were also correctly classified based on the SF levels of all quantified lipid species according to PCA and clustering analysis. Finally, the proteomic analysis quantified around 2,500 distinct proteins in the ST, including several related with lipid metabolism. Near 300 proteins showed altered abundance in the pathological tissues compared to healthy controls (FDR 0.01%, Figure 1A), being the small subset increased in controls mainly extracellular matrix proteins. The comparison between RA and PsA ST led to the identification of a panel of 36 proteins discriminating the two tissues with high statistical significance (p-value <0.01). In this comparison, all proteins except two appeared increased in RA (Figure 1B). A discriminant analysis shows the usefulness of this protein panel to differentiate the two diseases (Figure 1C).

Figure 1.

Results from the proteomic analysis carried out on synovial tissues. A) Heatmap showing the differential protein profiles between synovial tissues (PsA and RA) and healthy controls (CTL), at FDR 0.01. B) Characteristic protein panel discriminating PsA and RA tissues (p-value < 0.01). C) Discriminant analysis performed using this protein panel.

Conclusion

Our study shows distinct molecular profiles between RA and PsA synovial tissue and synovial fluid, and reports potential clinically useful lipid and protein markers for the differential diagnosis of these diseases.

Disclosure of Interests

None declared.

Correlation between plasmatic progesterone, endometrial receptivity genetic assay and implantation rates in frozen-thawed transferred euploid embryos. A multivariate analysis

OBJECTIVE

To ascertain the predictive value of different parameters to determine endometrial receptivity among assisted reproduction treatments in which single embryo transfer of frozen-thawed euploid blastocysts are performed.

STUDY DESIGN

Observational study involving 104 patients recruited between September.2018 and June.2019 at a University associated assisted reproduction center. The relationship of different parameters (age, body mass index (BMI), duration of hormonal preparation, plasmatic progesterone levels, endometrial parameters at ultrasound assessment and endometrial receptivity determined by endometrial receptivity assay (ERA) was evaluated by a multivariable logistic (binomial) analysis after hormonal preparation. According to the ERA test results a personalized endometrial transfer (pET) was scheduled and live birth rate was assessed. Only single transfers of frozen euploid blastocysts were performed.

RESULTS

ERA test report predicted receptive endometrium (RE) in 54,64% patients and non-receptive (NR) in 45,31% patients. Among NR endometrial samples, 20,62% were classified as pre-receptive or early receptive, whereas 24,74% as post-receptive or late-receptive. The univariate analysis showed a relationship between BMI, doses of progesterone administered before biopsy and the receptivity of endometrium. There was no relationship between age of women, duration of hormonal supplementation, and the results of ERA test. In our series, endometrial receptivity was not related neither to endometrial thickness nor plasmatic progesterone levels. The multivariate analysis showed that both, BMI and cumulative progesterone administered prior to the test are independent predictive factors of endometrial receptivity (p = 0,047 and p = 0,034 respectively). The overall live birth rate after FET of euploid embryos was 62,35%. The odd of pregnancy was higher when ERA test was performed prior to the first embryo transfer (93,10% vs. 46,43%; OR = 15,58;95%CI 3,38-71,89). Overall, ongoing pregnancy rates showed a favorable trend after "non-receptive" endometria had been diagnosed and, thus, a modified (pET) preparation was performed (70,00% vs. 55,56%; OR = 1,87; 95% CI 0,76-4,57).

CONCLUSION

Regarding implantation potential of genetically screened blastocysts, the traditional tools used for assessing endometrial receptivity such as transvaginal evaluation of endometrial thickness and pattern or progesterone levels determination were not useful among our patients for predicting a receptive endometrium.

FRI0053 PROLIFERATIVE SYNOVITIS, AN ULTRASOUND PATTERN ASSOCIATED WITH ACPA POSITIVE RHEUMATOID ARTHRITIS

Background:

Seronegative (sero-) and seropositive (sero+) Rheumatoid Arthritis (RA) have different genetic, immunopathological and vascular morphology features, but no previous studies have analyzed if US characteristics differ between sero+ or sero- RA. Our preliminary studies suggest that sero+ RA is associated with an expansive synovitis pattern that we have called “proliferative synovitis” (PS)

Objectives:

To analyze potential differences between patients with RA according to their autoantibody status by using ultrasonography (US). We aimed to assess whether PS is associated with ACPA+ pts

Methods:

We collected clinical, epidemiological data and bilateral carpal and hand US images of pts with RA. Synovial hypertrophy (SH), Power Doppler signal (PD) and total score (sum of scores of SH and PD) in wrist and hand (1-5 metacarpophalangeal) were assessed. We evaluated the presence of PS, defined as expansive synovial growth encompassing the concepts of synovial SH grade II and III. We performed synovial biopsies of a subgroup of pts using arthroscopy or US guided in order to see immunohistochemistry differences between “proliferative” and “flat” (non-proliferative) synovitis. Serum levels of angiogenic and inflammatory biomarkers were performed

Results:

Two hundred and five RA patients were collected. Overall, 173 (84.8%) pts were sero+ for RF (68.7%) or ACPA (74.6%), general characteristics are summarized in Table. No significant differences between sero+ and sero- pts in terms of disease activity or therapy were found. PS was present in 55.5% of sero+ pts (55.3% in RF+ and 58.2% in ACPA+ pts) and 16.1% of sero- pts (p=0.0001). Globally, 101 pts (49.2%) had PS. Ninety-six (95.0%) were RF or ACPA positive. Only 5 pts with sero- RA had PS (p=0.001). In the univariate analysis, significantly more pts with PS had erosive disease (72.3% vs 35.0% p=0.0001), higher US scores (p=0.0001) and more of them were taking conventional synthetic Disease-modifying anti-rheumatic drugs (csDMARD) (81.8% vs 69.6% p=0.05). No differences regarding disease activity were found.

In the multivariate analysis erosions [OR 4.90 CI 95% (2.17-11.07) p=0.0001] and ACPA [OR 3.5 CI 95% (1.39-10.7) p=0.09] but not RF status [OR 0.74 CI 95% (0.31-1.71) p=0.483] were independently associated with the presence of PS.

We immunostained synovial biopsies from 23 pts with PS (13 pts) or non-PS (10 pts). PS was significantly associated with higher density of vessels (p=0.042) and a strong trend to a higher density of B, T, Mast cells and macrophages (figure 1). Significantly higher serum levels of angiogenic (Activin A, bFGF, IL18, IL20, PIGF, SDF-1 and VEGF-D) and pro-inflammatory (IL23) cytokines were found in patients with PS (figure 2).

Conclusion:

The presence of “proliferative Synovitis” was significantly associated with ACPA and erosive disease in patients with RA. PS pattern also was associated with higher density of synovial vessels and higher serum levels of angiogenic and inflammatory mediators

Table .Total US pattern p valueN=205Proliferative (N=101)Non proliferative (N=104)Female, n (%)162 (79.4)79 (78.2)83 (80.6)0.57Age, mean (SD) years57.1 (± 14,1)56.3 (± 12.0)58.0 (± 15.9)0.40Current Smoker, n (%)47 (26.9)22 (25.6)25 (28.1)0.73Disease duration, mean (SD) months113.3 (± 105.7)127.7 (± 111.1)99.3 (± 99.3)0.05Erosion, n (%)108 (53.7)73 (72.3)35 (35.0)0.00ACPA, n (%)153 (75.4)89 (89)64 (62.1)0.00RF, n (%)99 (68.3)78 (78)63 (61.2)0.01DAS 28–CRP, mean (SD)2.55 (±1.03)2.66 (±1.04)2.44 (±1.02)0.17GC, n (%)99 (49.3)45 (45.5)54 (52.9)0.32cDMARDs, n (%)152 (75.6)81 (81.8)71 (69.6)0.05bDMARD, n (%)69 (34.3)35 (35.4)34 (33.3)0.76Total US score14.9 (± 11.5)18.8 (± 11.8)11.1 (± 9.9)0.00

*ACPA anti-citrullinated protein antibodies, RF rheumatoid factor, DAS28-CRP Disease Activity Score 28-joint count, CRP C-reactive protein, GC glucocorticoids, bDMARD biological disease-modifying antirheumatic drugs

Disclosure of Interests:

Ana Belén Azuaga-Piñango: None declared, Beatriz Frade-Sosa: None declared, Roberto Gumucio: None declared, Katherine Cajiao: None declared, Andrea Cuervo: None declared, Raquel Celis: None declared, Jose A. Gómez-Puerta Speakers bureau: Abbvie, BMS, GSK, Lilly, Pfizer, Roche, Raimón Sanmartí Speakers bureau: Abbvie, Eli Lilly, BMS, Roche and Pfizer, Juan de Dios Cañete: None declared, Julio Ramirez: None declared

Blind colour separation of H&E stained histological images by linearly transforming the colour space

Blind source separation methods aim to split information into the original sources. In histology, each dye component attempts to specifically characterize different microscopic structures. In the case of the hematoxylin-eosin stain, universally used for routine examination, quantitative analysis may often require the inspection of different morphological signatures related mainly to nuclei patterns, but also to stroma distribution. Stain separation is usually a preprocessing operation that is transversal to different applications. This paper presents a novel colour separation method that finds the hematoxylin and eosin clusters by projecting the whole (r,g,b) space to a folded surface connecting the distributions of a series of [(r-b),g] planes that divide the cloud of H&E tones. The proposed method produces density maps closer to those obtained with the colour mixing matrices set by an expert, when comparing with the density maps obtained using nonnegative matrix factorization (NMF), independent component analysis (ICA) and a state-of-the-art method. The method has outperformed three baseline methods, NMF, Macenko and ICA, in about 8%, 12% and 52% for the eosin component, whereas this was about 4%, 8% and 26% for the hematoxylin component.

Environmental behavior of the enantiomers of the chiral fungicide metalaxyl in Mediterranean agricultural soils

Improving the existing knowledge on the enantioselectivity of processes affecting chiral pesticide enantiomers in the environment is necessary to maximize the efficacy and minimize the environmental impact caused by the use of pesticides with chiral properties. In this work, the enantioselectivity of the sorption, degradation, and leaching processes of the chiral fungicide metalaxyl in three slightly alkaline, agricultural soils from southern Spain was studied. Batch sorption experiments indicated that the sorption of racemic-metalaxyl on soils, their clay (<2 μm) fractions, and a number of model sorbents simulating naturally-occurring soil colloidal particles was non-enantioselective; the S-enantiomer was sorbed to the same extent as the R-enantiomer on all soil materials. Soil incubation experiments revealed that the R-enantiomer of metalaxyl was degraded faster than the S-enantiomer in all three soils, but the extent and enantioselectivity of metalaxyl degradation was soil-dependent, occurring more slowly and with less enantioselectivity in the fine-textured soil (soil 1) than in the coarse-textured soils (soils 2 and 3). For soils 2 and 3, S- and R-metalaxyl dissipation data were very well described by single first-order kinetics, whereas for soil 1 dissipation data were better fitted by two coupled first-order equations. It is suggested that sorption and entrapment of metalaxyl enantiomers in the abundant small-size pores of soil 1 (i.e., pore radius<100 nm) could have resulted in a fraction of the fungicide of reduced bioavailability, and consequently, protected from enantioselective degradation. Metalaxyl leaching through soil columns was also enantioselective; the concentration of S-metalaxyl in all leachates collected was greater than that of R-metalaxyl. Despite being non-enantioselective, sorption influenced the enantioselectivity of metalaxyl leaching, as it determined the residence time of the fungicide within the soil column, and consequently, the extent and enantioselectivity of its degradation during leaching.

Organo/LDH nanocomposite as an adsorbent of polycyclic aromatic hydrocarbons in water and soil-water systems

Polycyclic aromatic hydrocarbons (PAHs) are considered as priority pollutants because of their high risk to human health. In this paper, we addressed the issue of using hydrotalcite-based nanocomposites as adsorbents of six low molecular weight PAHs (acenaphthene, fluorene, phenanthrene, anthracene, fluoranthene and pyrene) to reduce their negative effects on the environment. A nanocomposite (HT-DDS) was prepared by intercalating the organic anion dodecylsulfate (DDS) in a Mg-Al hydrotalcite (HT), and then characterized using several analytical techniques. A Mediterranean soil was selected for being a high-risk scenario of groundwater contamination by leaching of pollutants. The nanocomposite displayed enhanced affinity for the PAHs in water as compared to carbonate-hydrotalcite (HTCO(3)) and its calcined product (HT500), and showed a high irreversibility of the adsorption process (hysteresis coefficient, H<0.15). The results revealed an increase of the pollutants retention in the soil by the addition of the nanocomposite that depended on the nanocomposite application rate and also on the hydrophobicity of each PAH. Accordingly, the use of HT-DDS as an amendment or barrier in contaminated soil is proposed for reducing the mobility of PAHs and, consequently, the adverse effect derived from rapid transport losses of the pollutants to the adjoining environmental compartments.

Effect of olive-mill waste addition to soil on sorption, persistence, and mobility of herbicides used in Mediterranean olive groves

Laboratory and field experiments were conducted to evaluate the effect of olive-mill waste (OMW) addition to a Mediterranean olive grove soil on sorption, persistence, and mobility of two herbicides which are simultaneously applied for weed control in olive groves: terbuthylazine (TA) and fluometuron (FM). Laboratory batch sorption experiments showed that OMW addition to the soil at rates of 5 and 10% (w/w) greatly enhanced the sorption of both herbicides, thus suggesting that amendment with OMW could be useful to enhance the retention and reduce the mobility of FM and TA in the soil. Incubation experiments showed that OMW increased the persistence of FM and had little effect on the long persistence of TA in the soil studied. A demonstration field experiment was also conducted in field plots with a slope of about 5%, either unamended or amended with OMW at a rate of 10 kg m⁻², and then treated with a commercial formulation containing a mixture of TA and FM. Extraction of field soil samples, taken from different soil depths (0-5, 5-10, 10-20, and 20-30 cm) at different times after herbicide application, showed that both TA and FM moved deeper in unamended soil than in OMW-amended soil, and that OMW addition affected the persistence of FM in the toplayer, increasing its half-life from 24 to 58 days, while having little effect on the persistence of TA. Thus, data obtained under real field conditions were consistent with those obtained under controlled laboratory conditions. Preliminary herbicide runoff data indicated that the total herbicide runoff losses were also reduced upon OMW addition. Addition of OMW could be beneficial in reducing the mobility of TA and FM in olive grove soils, and also in increasing the persistence of FM in soils where this herbicide could be rapidly degraded.

Montmorillonite-chitosan bionanocomposites as adsorbents of the herbicide clopyralid in aqueous solution and soil/water suspensions

Montmorillonite (SWy-2)-chitosan bionanocomposites (SW-CH) were prepared following different methodologies, characterized, and assayed as adsorbents of the herbicide clopyralid (3,6-dichloropyridine-2-carboxylic acid) in aqueous solution and soil/water suspensions, to assess the potential of the materials to prevent and remediate soil and water contamination by anionic pesticides. The SW-CH bionanocomposites were good adsorbents for the herbicide at pH levels where both the anionic form of the herbicide (pK(a)=2.3) and the cationic form of CH (pK(a)=6.3) predominated. The performance of the SW-CH bionanocomposites as adsorbents of clopyralid depended on the amount and arrangement of chitosan in the samples. Clopyralid adsorption was rapid and mostly linear up to herbicide concentrations as high as 0.5mM. High salt concentrations (0.1M NaCl) promoted desorption of the adsorbed pesticide from SW-CH, strongly suggesting that adsorption of clopyralid occurred primarily through an ion exchange mechanism on positively charged CH sites at the montmorillonite surface. Amendment of an acidic soil (pH=4.5) with SW-CH at rates of 5% and 10% led to a significant increase in clopyralid adsorption, whereas this effect was negligible when SW-CH was added to an alkaline soil (pH=8.0), reflecting the absence of positively charged sites in SW-CH at high pH values. Montmorillonite-CH bionanocomposites can be useful as adsorbents for the removal and/or immobilization of anionic pesticides in soil and water under mild acidic conditions.

Layered double hydroxides as adsorbents and carriers of the herbicide (4-chloro-2-methylphenoxy)acetic acid (MCPA): systems Mg-Al, Mg-Fe and Mg-Al-Fe

Hydrotalcite-like compounds [Mg(3)Al(OH)(8)]Cl x 4H(2)O; [Mg(3)Fe(OH)(8)]Cl x 4H(2)O; [Mg(3)Al(0.5)Fe(0.5)(OH)(8)]Cl x 4H(2)O (LDHs) and calcined product of [Mg(3)Al(OH)(8)]Cl x 4H(2)O, Mg(3)AlO(4.5) (HT500), were studied as potential adsorbents of the herbicide MCPA [(4-chloro-2-methylphenoxy)acetic acid] as a function of pH, contact time and pesticide concentration, and also as support for the slow release of this pesticide, with the aim to reduce the hazardous effects that it can pose to the environment. The information obtained in the adsorption study was used for the preparation of LDH-MCPA complexes. The results showed high and rapid adsorption of MCPA on the adsorbents as well as that MCPA formulations based on LDHs and HT500 as pesticide supports displayed controlled release properties and reduced herbicide leaching in soil columns compared to a standard commercial MCPA formulation. Thereby, we conclude that the LDHs employed in this study can be used not only as adsorbents to remove MCPA from aqueous solutions, but also as supports for the slow release of this highly mobile herbicide, thus controlling its immediate availability and leaching.

Influence of variants of Fc gamma receptors IIA and IIIA on the American College of Rheumatology and European League Against Rheumatism responses to anti-tumour necrosis factor alpha therapy in rheumatoid arthritis

OBJECTIVE

Fc gamma receptor (Fc gammaR) polymorphism influences the affinity of the receptor for Ig, which may, in turn, affect the efficacy of Ig-based therapies. The relationship between functional single nucleotide polymorphisms (SNP) of the FCGR2A and FCGR3A genes and the response to anti-tumour necrosis factor (TNF)alpha therapy (infliximab) in patients with rheumatoid arthritis (RA) was assessed.

METHODS

A total of 91 patients with RA (89% female; 76.7% rheumatoid factor (RF) positive) starting therapy with infliximab were evaluated at 0, 6 and 30 weeks using the American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) response criteria and the 28-joint Disease Activity Score (DAS28) was evaluated using three parameters, including C-reactive protein (CRP) (DAS28 3v-CRP) changes during the follow-up. Genotyping of FCGR2A-R131H and FCGR3A-F158V polymorphisms was performed by allele-specific PCR and PCR sequence-based typing, respectively. The chi(2) and Fisher exact tests were used to show differences in the outcome variables, and analysis of variance (ANOVA) to analyse the evolution of DAS28 3v-CRP. A generalised linear models multivariable analysis was also performed.

RESULTS

At week 6 of follow-up, the proportion of patients achieving 50% improvement as per ACR criteria (ACR50) and EULAR good responses were significantly higher among homozygotes of the low affinity FCGR3A allele (FF: 24.1% and VV-VF:2.2%; p = 0.003 and FF: 44.8% and VV-VF: 22.9%; p = 0.040, respectively). At week 30, homozygotes of the low affinity FCGR2A allele had a better ACR20 response (RR: 60% and HH-RH: 33.3%; p = 0.035). Changes in DAS28 3v-CRP during follow-up were consistent with those observed in ACR and EULAR responses.

CONCLUSIONS

The response to anti-TNFalpha treatment with infliximab in patients with RA is influenced by the FCGR2A and FCGR3A genotypes. This effect is observed at different times in the follow-up (6 and 30 weeks, respectively) indicating the dynamic nature of the Fc gammaR versus Ig interaction.

Clinical significance of synovial lymphoid neogenesis and its reversal after anti-tumour necrosis factor α therapy in rheumatoid arthritis

Objective:

To investigate the clinical significance of lymphoid neogenesis (LN) in rheumatoid arthritis (RA), the clinicopathological correlates of this process and its evolution after anti-tumour necrosis factor (TNF)α therapy in a large series of synovial tissues were analysed.

Methods:

Arthroscopic synovial biopsies from 86 patients with RA were analysed by immunohistochemistry. LN was defined as the presence of large aggregates of lymphocytes with T/B cell compartmentalisation and peripheral node addressin (PNAd) positive high endothelial venules. Clinical variables at baseline and after prospective follow-up were compared in LN positive and negative RA subsets. The evolution of LN and its correlation with the clinical course in a subgroup of 24 patients that underwent a second arthroscopic biopsy after anti-TNFα therapy was also analysed.

Results:

LN was present in 49% of RA synovial tissues. Patients with LN had a significantly higher disease duration and a higher previous use of anti-TNFα agents. During prospective follow-up, the proportion of patients achieving good or moderate European League Against Rheumatism (EULAR) 28-joint Disease Activity Score (DAS28) responses was significantly lower in patients who were LN positive despite a significantly higher use of anti-TNFα agents. By multivariate logistic regression analysis, LN remained as an independent negative predictor of response to therapy. In the subgroup of patients rebiopsied after anti-TNFα therapy, reversal of LN features occurred in 56% of the patients and correlated with good clinical responses.

Conclusions:

Synovial LN in RA predicts a lower response to therapy. LN features can be reversed after a short period of anti-TNFα therapy in parallel to good clinical responses.

The prevalence of HFE C282Y gene mutation is increased in Spanish patients with porphyria cutanea tarda without hepatitis C virus infection

OBJECTIVES

To investigate the role of C282Y and H63D mutations, and hepatitis C virus (HCV) infection in the pathogenesis of porphyria cutanea tarda (PCT).

DESIGN

Prospective case-control study.

SETTING

A large clinical and research institute for the study and treatment of cutaneous diseases in Barcelona, Spain.

PATIENTS

Ninety-nine consecutive patients with PCT and one hundred and twenty-six control patients (76 healthy subjects and 50 patients chronically infected with HCV), were recruited.

MAIN OUTCOME MEASURES

The frequency of the C282Y and H63D mutations in patients with PCT vs. controls and the relationship of these mutations with HCV infection, and iron status, as judged by serum iron, liver iron and ferritin levels.

RESULTS

C282Y mutation was significantly increased in PCT patients. This mutation was more frequent among non-HCV-infected patients. Increased ferritin levels and hepatic iron overload were also observed in PCT patients with heterozygous C282Y state. H63D mutation was only significantly increased among PCT patients with chronic hepatitis C infection. No significant iron overload was observed in patients with H63D mutation.

CONCLUSIONS

This study confirms the high frequency of C282Y mutation in patients with PCT and its relationship with iron overload. The C282Y mutation has a relevant role in Spanish patients with PCT not associated with HCV chronic infection. On the other hand, the prevalence of the H63D mutation seems not to be increased in patients with PCT. The possibility of an association between HCV infection and H63D mutation in inducing PCT can be hypothesized.

Community-acquired pneumonia in the elderly: Spanish multicentre study

Community-acquired pneumonia (CAP) in the elderly has increased as a consequence of an overall increase of the elderly population. A controversy about the aetiology and outcome of CAP in this population still exists and more epidemiological studies are needed. A prospective, 12-month, multicentre study was carried out to assess the clinical characteristics, aetiology, evolution and prognostic factors of elderly patients (> or = 65 yrs) admitted to hospital for CAP. The study included 503 patients (age 76 +/- 7 yrs). The clinical picture lasted < or = 5 days in 318 (63%) and the main clinical features were cough (n = 407, 81%) and fever (n = 380, 76%). Aetiological diagnosis was achieved in 199 (40%) cases, with a definite diagnosis obtained in 164 (33%). Of the 223 microorganisms isolated the main agents found were Streptococcus pneumoniae in 98 (49%) and Haemophilus influenzae in 27 (14%). A total of 53 patients died (11%) and the multivariate analysis showed the following factors of bad prognosis: previous bed confinement, alteration in mental status, absence of chills, plasma creatinine > or = 1.4 mg x dL(-1), oxygen tension in arterial blood/inspiratorv oxygen fraction ratio < 200 at the time of admission, and shock and renal failure during the evolution. The results of this study may aid in the management of empiric antibiotic treatment in elderly patients with community-acquired pneumonia and the patients who have a greater probability of bad evolution may be identified based on the risk factors.

Adsorption of imidazolinone herbicides on smectite-humic acid and smectite-ferrihydrite associations

Adsorption of imazapyr (IMZ), imazethapyr (IMZT), and imazaquin (IMZQ) was studied on two smectite-humic acid and two smectite-ferrihydrite binary systems prepared by treating a Wyoming smectite with a humic acid extracted from soil (4 and 8% w/w of the smectite) and with just-precipitated synthetic ferrihydrite (8 and 16% w/w of the smectite). Adsorption of the three herbicides on the smectite was not measurable at pH >4.5, presumably because of negative charges on the surface of the smectite. Adsorption on the smectite-humic acid systems was also not measurable, presumably because of negative charges on the surface, despite the high affinity of the three herbicides for humic acid, the adsorption order of which was IMZ < IMZT << IMZQ. Adsorption decreased in the order IMZ < IMZT < IMZQ on the smectite-ferrihydrite systems and IMZQ < IMZT < IMZ on ferrihydrite, although here the differences were small. These results show that even though pure smectite cannot adsorb herbicides, it modifies the adsorption capacity of ferrihydrite. The mutual interaction of active phases such as humic acid, ferrihydrite, and smectite alters the characteristics of the resulting surface and hence the adsorption process. Investigations of herbicide adsorption have been seen to produce more reliable results if conducted on polyphasic systems rather than on single soil components.

Adsorption of imidazolinone herbicides on ferrihydrite-humic acid associations

Adsorption of the imidazolinone herbicides imazapyr, imazethapyr and imazaquin was studied on two binary systems (ferrihydrite-humic acid) prepared by treating ferrihydrite (Fh) immediately after its precipitation with a soil humic acid (HA) at different loadings (4% and 8% HA content), and on a blank ferrihydrite sample prepared in the same way, but without HA addition. Imidazolinone adsorption on pure Fh and on the 4% Fh-HA decreased with increasing of the herbicide hydrophobicity (imazaquin<imazethapyr<imazapyr), whereas on the 8% Fh-HA system the order of adsorption was nearly the same, indicating that higher amounts of HA on Fh increase the hydrophobicity of the surface and thus increases its affinity for the herbicides, specially for imazaquin. Adsorption was also enhanced by low pH values and slight changes in pH enhanced the contribution of each component in adsorption. Both the nature of the surface exposed and its ability to interact with herbicides are greatly altered by the mutual interaction of Fh and HA. The results show that albeit artificial polyphasic associations are more representative of the real situation than single model components and are thus better indicators of the behaviour of a given herbicide in the soil.

Evaluation of antimicrobial treatment in mechanically ventilated patients with severe chronic obstructive pulmonary disease exacerbations

OBJECTIVE

To study microbial and susceptibility patterns and antimicrobial treatment responses in patients with severe, acute exacerbations of chronic obstructive pulmonary disease requiring mechanical ventilation.

DESIGN

Microbial investigation using tracheobronchial aspirates, bronchoscopy with a protected specimen brush, and bronchoalveolar lavage, as well as paired serologies. Evaluation of antimicrobial treatment by results of the initial investigation, susceptibility testing, and a repeated microbial investigation (tracheobronchial aspirates, bronchoscopy with a protected specimen brush, and bronchoalveolar lavage) after 72 hrs.

SETTING

A respiratory intensive care unit of a 1,000-bed teaching hospital.

PATIENTS

Fifty severely exacerbated and mechanically ventilated patients with chronic obstructive pulmonary disease.

INTERVENTIONS

Initial empirical antimicrobial treatment according to clinical judgment.

MEASUREMENTS AND MAIN RESULTS

Overall, 36 of 50 patients (72%) had evidence of a microbial origin. Community-acquired endogenous pathogens were present in 70% of patients, and Gram-negative enteric bacilli and Pseudomonas/Stenotrophomonas species were present in 30%. All five isolates of Streptococcus pneumoniae were resistant to penicillin (three intermediately and two highly), and three were resistant to multiple antibiotics. Pseudomonas species revealed multiresistance in four of nine isolates (44%), and Stenotrophomonas maltophilia revealed multiresistance in one of two isolates. Antimicrobial treatment was modified according to diagnostic results in 11 of 31 patients (36%) with potentially pathogenic microorganisms. In patients who underwent a repeat investigation after 72 hrs, 24% of the initially present and potentially pathogenic microorganisms persisted. Inappropriate initial antimicrobial therapy was associated significantly with bacterial persistence (p < .002).

CONCLUSIONS

Considering the diversity of microbial pathogens and the resistance rates especially to S. pneumoniae in this patient population, antimicrobial treatment should be based on the constant study of local microbial and susceptibility patterns along with routine microbial investigation of the individual patient.

Natural soil colloids To retard simazine and 2,4-D leaching in soil

Natural or synthetic sorbents for pesticides can be used to reduce contamination of soils and natural waters. The sorption of simazine and 2,4-D on montmorillonite minerals has been studied and their potential use to retard pesticide leaching in soil evaluated. Simazine and 2,4-D did not sorb on high-layer charge montmorillonite, whereas sorption on the lower layer charge montmorillonite SWy varied depending on the saturating cation. Simazine sorption increased in the order Ca(2+)SWy << K(+)SWy < Fe(3+)SWy. Simazine molecules sorb on hydrophobic microsites of the montmorillonite. Once protonated, further sorption through cation exchange takes place in the interlamellar space of the montmorillonite, as corroborated by X-ray diffraction and FT-IR studies. 2,4-D does not sorb on K(+)SWy or Ca(2+)SWy, but does sorb on Fe(3+)SWy, because the acidic character of this sorbent allows the molecular form of 2, 4-D to sorb by hydrogen bonding and/or by hydrophobic interactions. Leaching experiments in hand-packed soil columns indicate that simazine and 2,4-D application as a complex with FeSWy renders later breakthrough and lower maximum concentration peaks, and the total herbicide leached is lower than when applied as the pure analytical grade compound. These results suggest the possible use of natural soil colloids as sorbents for herbicides such as simazine and 2,4-D to retard pesticide leaching in soil, thus reducing their ground water contamination potential.

Community-acquired pneumonia in the elderly

The incidence of community-acquired pneumonia (CAP) in the elderly is higher compared to younger populations. In addition, pneumonia in the elderly is a life-threatening problem. As our demographics have changed, clinicians have developed a heightened interest in managing pneumonia in the elderly. The development of pneumonia in elderly patients differs from that in younger individuals due to a complex array of factors. (1) The organisms involved depend on the setting in which the pneumonia developed: either the nonhospitalized elderly patient with CAP or the institutionalized patient who develops nursing-home-acquired pneumonia. (2) Underlying comorbid conditions commonly exist in the elderly that affect the etiology and outcome of pneumonia. Overall, Streptococcus pneumoniae and Haemophilus influenzae are still the most common etiologies of pneumonia in the elderly. The true role of gram-negative bacilli remains unclear although these micro-organisms may be more common etiologic agents in nursing-home pneumonia. Some recent studies from Mediterranean areas have reported high rates of infection by Chlamydia pneumoniae, but the real role of this micro-organism has to be confirmed. Another important issue is that the presenting symptoms of pneumonia in the elderly can be subtle and sometimes difficult to recognize. Fever is frequently absent, and delirium or alteration of functional physical capacity may be the only manifestations. Mortality in the elderly with CAP is higher when compared to younger populations. However, this may be explained by the concomitant presence of comorbid conditions more than by age per se. This statement has to be kept in mind when considering hospital and, particularly, intensive care unit admissions. Finally, antibiotic pharmacokinetics in the elderly populations with CAP ought to be considered to avoid frequent side-effects and complications. Overall, antibiotic regimens in hospitalized elderly patients with CAP do not differ from other hospitalized CAP populations. An organized approach to assessing elderly patients with suspicion of pneumonia and an awareness of common pitfalls in the management of this pulmonary infection in this population are essential to improving outcomes.

[Experience with laparoscopic surgery for adnexal masses at the Regional Hospital of Temuco, Chile]

BACKGROUND

Laparoscopic surgery has clear advantages over open surgical procedures. In gynecology, laparoscopic surgery for adnexal masses in pre or post menopausal women has been used for several years.

AIM

To report the experience with gynecologic laparoscopic surgery at the Temuco Regional Hospital.

PATIENTS AND METHODS

Between 1996 and 1998, laparoscopic surgery was done in 96 patients aged 16 to 56 years and open surgery in 56 patients aged 15 to 74 years, with a clinical or ultrasound diagnosis of adnexal masses or ovarian dermoid cysts.

RESULTS

The most frequent tumors excised were epithelial and germinal cell. Laparoscopic surgery required a mean operative time of 69.9 min and it had a 3.1% of complications. Women subjected to this type of surgery had a mean hospital stay of 3.1 days and the mean postoperative stay was 2 days. Open surgery required an operative time of 69 min and it had no postoperative complications. The mean hospital stay for women subjected to this type of procedure was 9.5 days.

CONCLUSIONS

Women subjected to laparoscopic surgical procedures for adnexal masses had a shorter hospital stay than women subjected to open surgical procedures.

An isotopic exchange method for the characterization of the irreversibility of pesticide sorption-desorption in soil

An isotopic exchange method is presented that characterizes the irreversibility of pesticide sorption-desorption by soil observed in batch equilibration experiments. The isotopic exchange of (12)C- and (14)C-labeled triadimefon [(1-(4-chlorophenoxy)-3,3-dimethyl-1-(1H-1, 2,4-triazol-1-yl)-2-butanone] and imidacloprid-guanidine [1-[(6-chloro-3-pyridinyl)methyl]-4,5-dihydro-1H-imidazol-2-amine] in Hanford sandy loam soil indicated that these systems can be described by a two-compartment model in which about 90% of sorption occurs on reversible, easily desorbable sites, whereas 10% of the sorbed molecules are irreversibly sorbed on soil and do not participate in the sorption-desorption equilibrium. This model closely predicted the hysteresis observed in the desorption isotherms from batch equilibration experiments. The isotopic exchange of triadimefon and imidacloprid-guanidine in Drummer silty clay loam soil indicated that there was a fraction of the sorbed (14)C-labeled pesticide that was resistant to desorption, which increased as pesticide concentration decreased and was higher for triadimefon than for imidacloprid-guanidine. In contrast, the batch equilibration method resulted in ill-defined desorption isotherms for the Drummer soil, which made accurate desorption characterization problematic.

Sorption and desorption of triadimefon by soils and model soil colloids

Sorption-desorption of the azole fungicide triadimefon [1-(4-chlorophenoxy)-3,3-dimethyl-1-(1H-1,2, 4-triazol-1-yl)-2-butanone] on eight soils and a series of single, binary, and ternary model soil colloids was determined using the batch equilibration technique. Regression analysis between Freundlich sorption coefficients (K(f)) and soil properties suggested that both clay and organic C (OC) were important in triadimefon sorption by soils, with increasing importance of clay for soils with high clay and relatively low OC contents. Triadimefon sorption coefficients on soil were not significantly affected by the concentration of electrolyte or the presence of soluble soil material in solution, but they were highly dependent on the soil:solution ratio due to the nonlinearity of triadimefon sorption on soil. Freundlich sorption isotherms slopes were very similar for all soils (0.75 +/- 0.02). Desorption did not greatly depend on the concentration at which it was determined and showed higher hysteresis for more sorptive soils. Results of triadimefon sorption on model sorbents supported that both humic acid and montmorillonite-type clay constituents contribute to triadimefon retention by soil colloids.

Bronchial microbial patterns in severe exacerbations of chronic obstructive pulmonary disease (COPD) requiring mechanical ventilation

We carried out a comprehensive microbiological study of the upper and lower airways in patients with severe exacerbations of chronic obstructive pulmonary disease (COPD) requiring mechanical ventilation in order to describe microbial patterns and analyze their clinical significance. Quantitative cultures of tracheobronchial aspirates (TBAs), bronchoscopically retrieved protected specimen brush (PSB) and bronchoalveolar lavage fluid (BALF) at admission to the ICU and after 72 h, as well as serology for bacteria and respiratory viruses were performed. Fifty patients (mean age 68 +/- 8, 46 males) were studied prospectively. Potentially pathogenic microorganisms (PPMs) and/or a positive serology were present in 36 of 50 (72%) patients, including 12 (33%) polymicrobial cases. Only six (12%) had no pathogen in any sample in the absence of antimicrobial pretreatment. Microbial patterns corresponded to community-acquired pathogens (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) in 19 of 34 (56%) and to gram-negative enteric bacilli (GNEB), Pseudomonas, and Stenotrophomonas spp. in 15 of 34 (44%) of isolates. Chlamydia pneumoniae and respiratory viruses were found in 18% and 16% of investigations, respectively. Repeated investigation after 72 h in 19 patients with PPMs in the initial investigation revealed eradication of virtually all isolates of community-acquired pathogens and GNEB but persistence of three of five Pseudomonas spp. and both Stenotrophomonas spp. as well as the emergence of new GNEB, Pseudomonas and Stenotrophomonas spp. Clinical parameters neither predicted the presence of PPMs nor of GNEB and Pseudomonas/Stenotrophomonas spp. Nevertheless, severe pneumonia attributable to initially isolated pathogens occurred in two patients with severe COPD exacerbation. We conclude that pathogens were more frequently present than previously reported. The rate of GNEB and Pseudomonas/Stenotrophomonas spp. isolates was high. The presence of pathogens was clinically unpredictable. Thus, in this population of patients with severe exacerbations of COPD, it may be advisable to obtain respiratory samples and to treat according to diagnostic results. Further studies are warranted to clarify this issue.

Bacterial colonization of distal airways in healthy subjects and chronic lung disease: a bronchoscopic study

In contrast to the healthy population, distal airway bacterial colonization may occur in patients with chronic lung diseases, who often have altered pulmonary defences. However, the information dealing with this issue is insufficient and is based mainly on nonspecific samples, such as sputum cultures. Using quantitative cultures of bronchoscopic protected specimen brush (PSB) and bronchoalveolar lavage (BAL) samples, we studied the bacterial colonization of distal airways in 16 healthy subjects, 33 patients with bronchogenic carcinoma, 18 with chronic obstructive pulmonary disease (COPD), 17 with bronchiectasis, and 32 with a long-term tracheostomy due to laryngeal carcinoma. All patients were without exacerbation, and free from antibiotic treatment at least 1 month before the study protocol. Thresholds for quantitative cultures to define colonization were > or = 10(2) colony-forming units (cfu) x mL(-1) for PSB and > or = 10(3) cfu x mL(-1) for BAL. Only one healthy subject was colonized by a potential pathogenic microorganism (PPM) (Staphylococcus aureus 4x10(2) cfu x mL(-1) in a PSB culture). Colonization was observed in 14 (42%) bronchogenic carcinoma patients (19 non-PPMs, and 10 PPMs); in 15 (83%) COPD patients (22 non-PPMs and 7 PPMs); in 15 (88%) bronchiectasis patients (20 non-PPMs and 13 PPMs); and in 15 (47%) long-term tracheostomy patients (5 non-PPMs and 13 PPMs). The two most frequent non-PPMs isolated in all groups studied were Streptococcus viridans and Neisseria spp. Haemophilus spp., Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis were the most frequent PPMs isolated in bronchogenic carcinoma, COPD, bronchiectasis and long-term tracheostomized patients, respectively. Pseudomonas aeruginosa colonization was infrequent in all the groups. Our results show that distal airway bacterial colonization is a frequent feature in stable patients with chronic lung diseases and also in patients with long-term tracheostomy. However, the pattern of colonization differs among groups studied. The knowledge of different colonization patterns may be important for future antibiotic prophylactic strategies and for the empirical antibiotic regimens when exacerbations occur in these patients.

Community-acquired pneumonia in chronic obstructive pulmonary disease: a Spanish multicenter study

Community-acquired pneumonia (CAP) is an infectious illness that frequently motivates hospital admission when comorbid conditions are present. However, the epidemiology of CAP in relation to the underlying disease of the patients is not well known. We performed a prospective multicenter study with the aim of assessing the clinical characteristics, etiology, and outcome of chronic obstructive pulmonary disease (COPD) patients with CAP. Between October 1992 and December 1994 we studied 124 COPD patients (mean FEV1 40 +/- 11% of predicted, mean FVC/FEV1 49 +/- 10) admitted because of CAP to one of the participating centers. An attempt to obtain an etiologic diagnosis was performed by means of blood cultures (n = 123), sputum cultures (n = 97), pleural fluid cultures (n = 17), protected specimen brush samples (n = 41), percutaneous transthoracic needle aspiration (n = 41), and serology (n = 106). Etiologic diagnosis was achieved in 80 (64%) of cases, however, diagnosis based upon valid techniques was only possible in 73 (59%) cases. The main causal microorganisms were the following: Streptococcus pneumoniae in 32 (43%), Chlamydia pneumoniae in 9 (12%), Hemophilus influenzae in 7 (9%), Legionella pneumophila in 7 (9%), Streptococcus viridans in 3 (4%), Coxiella burnetii in 3 (4%), Mycoplasma pneumoniae in 2 (3%), Nocordia asteroides 2, Aspergillus ssp. 1, and others 10. In three of these cases the etiology was polymicrobial. Bacteremia was present in 19 (15%) cases; S. pneumoniae was the most frequent isolate (13 cases). Antibiotic treatment was modified in 22 cases due to etiologic findings, and in 9 due to therapeutic failure. Ten patients died (8%), and 22 needed mechanical ventilation, the mortality rate in the latter population being 23%. Total or partial resistance of S. pneumoniae to penicillin was observed in 10 of 32 (31%) isolations, and to erythromycin in 2 (6%). The results of this study are important for the standardization of empiric antibiotic strategies in COPD patients with pneumonia.

Persistent hepatitis C viremia after acute self-limiting posttransfusion hepatitis C

Persistent viremia after clinical or subclinical hepatitis C virus (HCV) infection is believed to occur in patients with chronic hepatitis C, but little is known about the duration of HCV replication in patients with acute hepatitis who have recovered or the relation of HCV viremia with the kinetics of antibodies to HCV (anti-HCV). We tested HCV-RNA and anti-HCV in serial serum samples from 41 patients with posttransfusion non-A, non-B hepatitis, followed for an average of 6 years after transfusion. Serum HCV-RNA was measured by nested polymerase chain reaction, which used primers from the 5' untranslated region of the HCV genome. Anti-HCV were tested with first- and second-generation enzyme-linked immunosorbent assays (ELISA 1 and ELISA 2), and with a second-generation recombinant immunoblot assay. Of the 41 patients, 10 recovered and 31 progressed to chronic liver disease. HCV-RNA was detected in serum before or simultaneously with the onset of hepatitis in all cases, and lasted between 2 and 6 weeks in 5 of the 10 patients who recovered, whereas it persisted for the entire follow-up period in every case with chronic hepatitis and in the remaining 5 patients with self-limiting hepatitis. Anti-HCV were detected with ELISA 2 in the first serum sample, with raised serum transaminases in 57% of patients, but in only 6% with ELISA 1. In the sample obtained 1 month after the onset of hepatitis, anti-HCV were detected with ELISA 2 in 94% of patients, but in 34% with the ELISA 1.(ABSTRACT TRUNCATED AT 250 WORDS)

[Use of GnRH analogs in hysteroscopic surgery]

Hysteroscopic surgery has been widely used in gynaecology for the treatment of endocavitary fibroids, synechias, uterine septum and abnormal uterine bleeding. Reports proposed preoperative medical therapy to improve the endometrials conditions. Attempts at inhibiting the thickness and vascularity of the endometrium and to reduce the fibroids size in preparation for hysteroscopic surgery by using different types of hormones have been reported. The suppression provided for a long period of time after the procedure by gonadotropin releasing hormone (GnRH) analogs, is likely to help inhibit endometrial regeneration and provided even better long time success, in endometrial ablation and submucous leiomyomatas hysteroscopic surgery. A literature review of the efficiency of the gonadotropins releasing hormone agonist, in endometrial inhibition before surgery and small regional experience is shown.

Severe community-acquired pneumonia. Epidemiology and prognostic factors

Over a period of 4 consecutive yr, 92 nonimmunosuppressed patients (21 women and 71 men aged 53 +/- 16 yr, means = SD) with critical acute respiratory failure (PaO2/FiO2, 209 +/- 9 mm Hg) caused by severe community-acquired pneumonia were admitted to the respiratory intensive care unit (RICU) of a general hospital. The most frequent underlying clinical condition was chronic obstructive pulmonary disease (44 patients, 48%). A total of 56 patients (61%) required mechanical ventilation for a mean period of 10.7 +/- 12.5 days, 29 of them (52%) needing PEEP (9.9 +/- 3.8 cm H2O). A group of 23 (25%) patients had criteria of adult respiratory distress syndrome (ARDS). A causal microorganism was identified in 48 patients (52%), the two most frequent etiologies being Streptococcus pneumoniae (14, 15%) and Legionella pneumophila (13, 14%). Pseudomonas aeruginosa (5, 5%) was always associated with bronchiectasis. Mortality due to severe community-acquired pneumonia was 22% (20 patients). According to univariate analysis, mortality was associated with anticipated death within 4 to 5 yr, inadequate antibiotic treatment before RICU admission, mechanical ventilation requirements, use of PEEP, FIO2 greater than 0.6, coexistence of ARDS, radiographic spread of the pneumonia during RICU admission, septic shock, bacteremia, and P. aeruginosa as the cause of the pneumonia. Further, recursive partitioning analysis selected two factors significantly related to the prognosis: the radiographic spread of the pneumonia during RICU admission and the presence of septic shock.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of negative pressure ventilation on arterial blood gas pressures and inspiratory muscle strength during an exacerbation of chronic obstructive lung disease

The effects of intermittent negative pressure ventilation have been studied in 20 patients with chronic obstructive pulmonary disease during an exacerbation of their disease. Measurements of arterial blood gas tensions and maximal inspiratory pressure (MIP) were performed before and after six hours of negative pressure ventilation or standard treatment (control day) given in random order on two consecutive days. After negative pressure ventilation the mean (SD) value of MIP increased from 68.1 (21.5) to 74.8 (20) cm H2O;* arterial oxygen tension (PaCO2) fell from 60.6 (12.2) to 50.9 (8.9) mm Hg* but PaO2 changed little (from 48.4 (7.4) to 47.6 (8.2) mm Hg). There were no significant changes on the control day in arterial blood gas tensions (PaO2 47.8 (8.1) and 48.9 (9.4) and Paco2 59.8 (10.9) and 57.5 (8.06) mm Hg) or in MIP (69.4 (22.4) and 70.9 (22.9) cm H2O). Six patients tolerated negative pressure ventilation poorly and these patients showed less improvement after negative pressure ventilation. Our results suggest that intermittent negative pressure ventilation can increase alveolar ventilation in patients with an exacerbation of chronic obstructive lung disease, particularly in those who tolerate the procedure well. Most subjects showed a fall in PaCO2 and an increase in MIP. The fact that PaO2 was unchanged despite the fall in PaCO2 suggests that gas exchange may deteriorate with negative pressure ventilation in these patients.

Diagnostic value of nonfluoroscopic percutaneous lung needle aspiration in patients with pneumonia

In forty-one patients (mean [+/- SD] age 51 +/- 19 years; range, 11 to 88 years; seven female and 34 male) with clinical signs and symptoms of pneumonia, we performed a nonfluoroscopic percutaneous lung needle (22 gauges) aspiration (PLNA) to investigate the diagnostic yield of this technique. All the patients were receiving antibiotics at the time of the study, and PLNA was performed either because of a lack of response to empiric antibiotic treatment or because of the severity of the pneumonia or the underlying condition of the patient. Eight patients were mechanically ventilated (MV) due to acute respiratory failure. The PLNA was performed at bedside and without fluoroscopic guidance. Twenty-two microorganisms were identified by means of stains and/or cultures of PLNA samples. Sensitivity of PLNA was 43 percent (18/41). We detected three false-positive cultures probably due to contamination from the skin area punctured. In the eight MV patients studied, the sensitivity of PLNA was 37.5 percent, and the microbiologic findings turned out to be crucial for the outcome of the patients. Pneumothorax developed in three patients (7 percent) after PLNA. None of these three patients developed a pleural infection but two of them required thoracostomy drainage. None of the MV patients presented complications. Our results showed that nonfluoroscopic PLNA is a technique with moderately good sensitivity and with a low rate of false-positive cultures (8 percent) to diagnose pulmonary infections in patients with unresponsiveness to empiric antibiotic treatment or with severe pneumonia. Further evaluation of its diagnostic value and complications in MV patients is needed, although our preliminary results suggest that PLNA can be an alternative technique to other methods for diagnosing pulmonary infections in patients receiving artificial ventilatory support.

Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients

Seventy-eight (24%) episodes of nosocomial pneumonia (NP) were detected in 322 consecutive mechanically ventilated patients admitted to a 1,000-bed teaching hospital from April 1987 through May 1988 to assess the incidence, risk, and prognosis factors of NP acquired during mechanical ventilation (MV). The risk and prognosis factors for developing NP during MV were studied using both univariate and multivariate statistical techniques. Multivariate analysis selected the following variables significantly associated with a higher risk for developing ventilator-associated pneumonia: more than one intubation during MV (p = 0.000012), a prior episode of aspiration of gastric content (p = 0.00018), a MV period longer than 3 days (p = 0.015), the presence of chronic obstructive pulmonary disease (COPD) (p = 0.048), and the use of positive end-expiratory pressure (PEEP) during MV (p = 0.092). The presence of an ultimately or rapidly fatal underlying disease (p = 0.0018), worsening of acute respiratory failure caused by pneumonia (p = 0.0096), the presence of septic shock (p = 0.016), an inappropriate antibiotic treatment (p = 0.02), and the type of intensive care unit (ICU) hospitalization (noncardiac surgery and nonsurgical ICU compared with post-cardiac surgery ICU) (p = 0.08) were those factors selected by a stepwise logistic regression analysis as independently worsening the prognosis. The overall fatality rate was 23% (73 of 322). The mortality of patients with NP was higher (33%; 26 of 78; p less than 0.01) when compared with fatality rates of patients without NP (19%; 47 of 244).(ABSTRACT TRUNCATED AT 250 WORDS)