Ovarian cancer population screening and mortality after long-term follow-up in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial

BACKGROUND

Ovarian cancer continues to have a poor prognosis with the majority of women diagnosed with advanced disease. Therefore, we undertook the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) to determine if population screening can reduce deaths due to the disease. We report on ovarian cancer mortality after long-term follow-up in UKCTOCS.

METHODS

In this randomised controlled trial, postmenopausal women aged 50-74 years were recruited from 13 centres in National Health Service trusts in England, Wales, and Northern Ireland. Exclusion criteria were bilateral oophorectomy, previous ovarian or active non-ovarian malignancy, or increased familial ovarian cancer risk. The trial management system confirmed eligibility and randomly allocated participants in blocks of 32 using computer generated random numbers to annual multimodal screening (MMS), annual transvaginal ultrasound screening (USS), or no screening, in a 1:1:2 ratio. Follow-up was through national registries. The primary outcome was death due to ovarian or tubal cancer (WHO 2014 criteria) by June 30, 2020. Analyses were by intention to screen, comparing MMS and USS separately with no screening using the versatile test. Investigators and participants were aware of screening type, whereas the outcomes review committee were masked to randomisation group. This study is registered with ISRCTN, 22488978, and ClinicalTrials.gov, NCT00058032.

FINDINGS

Between April 17, 2001, and Sept 29, 2005, of 1 243 282 women invited, 202 638 were recruited and randomly assigned, and 202 562 were included in the analysis: 50 625 (25·0%) in the MMS group, 50 623 (25·0%) in the USS group, and 101 314 (50·0%) in the no screening group. At a median follow-up of 16·3 years (IQR 15·1-17·3), 2055 women were diagnosed with tubal or ovarian cancer: 522 (1·0%) of 50 625 in the MMS group, 517 (1·0%) of 50 623 in the USS group, and 1016 (1·0%) of 101 314 in the no screening group. Compared with no screening, there was a 47·2% (95% CI 19·7 to 81·1) increase in stage I and 24·5% (-41·8 to -2·0) decrease in stage IV disease incidence in the MMS group. Overall the incidence of stage I or II disease was 39·2% (95% CI 16·1 to 66·9) higher in the MMS group than in the no screening group, whereas the incidence of stage III or IV disease was 10·2% (-21·3 to 2·4) lower. 1206 women died of the disease: 296 (0·6%) of 50 625 in the MMS group, 291 (0·6%) of 50 623 in the USS group, and 619 (0·6%) of 101 314 in the no screening group. No significant reduction in ovarian and tubal cancer deaths was observed in the MMS (p=0·58) or USS (p=0·36) groups compared with the no screening group.

INTERPRETATION

The reduction in stage III or IV disease incidence in the MMS group was not sufficient to translate into lives saved, illustrating the importance of specifying cancer mortality as the primary outcome in screening trials. Given that screening did not significantly reduce ovarian and tubal cancer deaths, general population screening cannot be recommended.

FUNDING

National Institute for Health Research, Cancer Research UK, and The Eve Appeal.

Thrombogenic factors and recurrent coronary events

BACKGROUND

Thrombosis is a pivotal event in the pathogenesis of coronary disease. We hypothesized that the presence of blood factors that reflect enhanced thrombogenic activity would be associated with an increased risk of recurrent coronary events during long-term follow-up of patients who have recovered from myocardial infarction.

METHODS AND RESULTS

We prospectively enrolled 1045 patients 2 months after an index myocardial infarction. Baseline thrombogenic blood tests included 6 hemostatic variables (D-dimer, fibrinogen, factor VII, factor VIIa, von Willebrand factor, and plasminogen activator inhibitor-1), 7 lipid factors [cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, lipoprotein(a), apolipoprotein (apo)A-I, and apoB], and insulin. Patients were followed up for an average of 26 months, with the primary end point being coronary death or nonfatal myocardial infarction, whichever occurred first. The hemostatic, lipid, and insulin parameters were dichotomized into their top and the lower 3 risk quartiles and evaluated for entry into a Cox survivorship model. High levels of D-dimer (hazard ratio, 2.43; 95% CI, 1.49, 3.97) and apoB (hazard ratio, 1.82; 95% CI, 1.10, 3.00) and low levels of apoA-I (hazard ratio, 1.84; 95% CI, 1.10, 3.08) were independently associated with recurrent coronary events in the Cox model after adjustment for 6 relevant clinical covariates.

CONCLUSIONS

Our findings indicate that a procoagulant state, as reflected in elevated levels of D-dimer, and disordered lipid transport, as indicated by low apoA-1 and high apoB levels, contribute independently to recurrent coronary events in postinfarction patients.

Role of DNA methylation and epigenetic silencing of HAND2 in endometrial cancer development

BACKGROUND

Endometrial cancer incidence is continuing to rise in the wake of the current ageing and obesity epidemics. Much of the risk for endometrial cancer development is influenced by the environment and lifestyle. Accumulating evidence suggests that the epigenome serves as the interface between the genome and the environment and that hypermethylation of stem cell polycomb group target genes is an epigenetic hallmark of cancer. The objective of this study was to determine the functional role of epigenetic factors in endometrial cancer development.

METHODS AND FINDINGS

Epigenome-wide methylation analysis of >27,000 CpG sites in endometrial cancer tissue samples (n = 64) and control samples (n = 23) revealed that HAND2 (a gene encoding a transcription factor expressed in the endometrial stroma) is one of the most commonly hypermethylated and silenced genes in endometrial cancer. A novel integrative epigenome-transcriptome-interactome analysis further revealed that HAND2 is the hub of the most highly ranked differential methylation hotspot in endometrial cancer. These findings were validated using candidate gene methylation analysis in multiple clinical sample sets of tissue samples from a total of 272 additional women. Increased HAND2 methylation was a feature of premalignant endometrial lesions and was seen to parallel a decrease in RNA and protein levels. Furthermore, women with high endometrial HAND2 methylation in their premalignant lesions were less likely to respond to progesterone treatment. HAND2 methylation analysis of endometrial secretions collected using high vaginal swabs taken from women with postmenopausal bleeding specifically identified those patients with early stage endometrial cancer with both high sensitivity and high specificity (receiver operating characteristics area under the curve = 0.91 for stage 1A and 0.97 for higher than stage 1A). Finally, mice harbouring a Hand2 knock-out specifically in their endometrium were shown to develop precancerous endometrial lesions with increasing age, and these lesions also demonstrated a lack of PTEN expression.

CONCLUSIONS

HAND2 methylation is a common and crucial molecular alteration in endometrial cancer that could potentially be employed as a biomarker for early detection of endometrial cancer and as a predictor of treatment response. The true clinical utility of HAND2 DNA methylation, however, requires further validation in prospective studies. Please see later in the article for the Editors' Summary.

Early and long-term results of subclavian angioplasty in aortoarteritis (Takayasu disease): comparison with atherosclerosis

PURPOSE

To compare the early and long-term outcomes of subclavian artery angioplasty in patients with aortoarteritis and atherosclerosis.

METHODS

Sixty-one subclavian artery angioplasties were performed in 55 consecutive patients with aortoarteritis (n = 32) and atherosclerosis (n = 23) between 1986 and 1995. An arch aortogram followed by a selective subclavian artery angiogram was done to profile the site and extent of the lesion, its relation to the vertebral artery, and the distal circulation. Percutaneous transluminal angioplasty (PTA) was performed via the femoral route for 56 stenotic lesions and 5 total occlusions.

RESULTS

PTA was successful in 52 (92.8%) stenotic lesions and 3 (60%) total occlusions. Three patients (5.4%) had complications, that could be effectively managed nonsurgically. Compared with atherosclerosis, patients with aortoarteritis were younger (27.4 +/- 9.3 years vs 54.5 +/- 10.5 years; p < 0.001), more often female (75% vs 17.4%; p < 0.001), gangrene was uncommon (0% vs 17.4%; p < 0.05), and diffuse involvement was seen more often (43.8% vs 4.4%; p < 0.001). The luminal diameter stenoses were similar before PTA (88.6 +/- 9.7% vs 89.0 +/- 9.1%; p = NS). Higher balloon inflation pressure was required to dilate the lesions of aortoarteritis (9.9 +/- 4.6 ATM vs 5.5 +/- 1.0 ATM; p < 0.001). This group had more residual stenosis (15.5 +/- 12.4% vs 8.3 +/- 9.4%; p < 0.05) after PTA. There were no neurological sequelae, even in PTA of prevertebral lesions. On 3-120 months (mean 43.3 +/- 28.9 months) follow-up of 40 patients, restenosis was more often observed in patients with aortoarteritis, particularly in those with diffuse arterial narrowing. These lesions could be effectively redilated. Clinical symptoms showed marked improvement after successful angioplasty.

CONCLUSION

Subclavian PTA is safe and can be performed as effectively in aortoarteritis as in atherosclerosis, with good long-term results. Long-term follow-up shows that it provides good symptomatic relief.

Maternal and perinatal outcome in varying degrees of anemia

OBJECTIVES

To analyze the maternal and perinatal outcome in varying degrees of anemia.

METHODS

A total of 447 pregnant women were divided into group I (Hb>11 g%, n=123 women), group II (Hb 9-10.9 g%, n=214 women), group III (Hb 7-8.9 g%, n=79 women) group IV (Hb<7 g%, n=31 women). Their maternal and perinatal outcome, mode of delivery, duration of labor and postpartum complications were noted and analyzed using multiple logistic regression to calculate odds ratios (95% CI) for duration of labor, mode of delivery and low birth babies. Chi square or Fisher's exact test was employed for difference in proportions and Student's t-test for testing difference between means.

RESULTS

Mean age (27+/-4.25 years) and number of women with parity >3 were highest in group IV. The patients with Hb<8.9 g% had a 4-6-fold higher risk of prolonged labor compared to Hb>11 g%. The odds ratios for abnormal delivery (cesarean and operative vaginal deliveries) showed a 4.8-fold higher risk (95% CI 1.82, 12.7) in patients with Hb </=7.5 g%. The mean birth weight was maximum in the 9.6-10.5 g% category that fell with both increasing and decreasing hemoglobin values, being lowest in Group IV. Women in Group II had lowest number of low birth weight and IUGR babies, no stillbirths and neonatal deaths, lowest induction and operative delivery rates.

CONCLUSIONS

Mild anemia fared best in maternal and perinatal outcome. Severe anemia was associated with increased low birth weight babies, induction rates, operative deliveries and prolonged labor.

Curcumin loaded solid lipid nanoparticles ameliorate adjuvant-induced arthritis in rats

BACKGROUND

Rheumatoid arthritis (RA), a chronic and systemic inflammation, results in destruction of joints and cartilages. Effectiveness of curcumin has been established in a wide variety of inflammatory disorders, but its utility as a therapeutic agent is limited by its poor absorption, rapid metabolism and fast systemic elimination. To apprehend these limitations, we propose to use highly bioavailable curcumin loaded solid lipid nanoparticles (C-SLNs) for the treatment of RA.

METHODS

In the present study, the protective effect of curcumin and its SLNs was evaluated in complete Freund's adjuvant (CFA)-induced arthritis in rats.

RESULTS

Arthritic rats exhibited marked decrease in paw withdrawal threshold in Randall-Selitto and von Frey hair test along with decreased reaction time in hot plate. Arthritic rats also showed significant joint hyperalgesia, joint stiffness and increased paw volume along with marked decrease in mobility score. Arthritic rats showed a significant increase in blood leukocyte count, oxidative-nitrosative stress, tumour necrosis factor-α, C-reactive protein, cyclic citrullinated peptide antibody levels and radiological alterations in tibiotarsal joint. C-SLN administration (10 and 30 mg/kg), when compared with free curcumin (10 and 30 mg/kg), significantly and dose dependently ameliorated various symptoms of arthritis in rats, improved biochemical markers and preserved radiological alterations in joints of arthritic rats.

CONCLUSIONS

The current findings suggest the protective potential of curcumin-SLNs in ameliorating CFA-induced arthritis in rats through attenuation of oxido-inflammatory and immunomodulatory cascade. Further, the results emphasize that SLNs are a novel approach to deliver curcumin into the inflamed joints and improve its biopharmaceutical performance.

Percutaneous transluminal angioplasty for renovascular hypertension in children: initial and long-term results

OBJECTIVE

To evaluate the efficacy and safety of percutaneous transluminal renal angioplasty (PTRA) in children.

METHODS

We performed aortography and attempted PTRA in 35 consecutive children (age 5 to 14 years, mean 10.8 +/- 2.5 years) with severe hypertension having > or = 75% renal artery stenosis (RAS).

RESULTS

The stenosis was caused by aortoarteritis in 31 (88.6%) cases and by juvenile idiopathic fibromuscular disease (FMD) in four (11.4%) cases. Twenty-seven (77.1%) patients, including three having RAS of solitary functioning kidney with total occlusion of contralateral renal artery, had bilateral RAS and eight (22.9%) had unilateral RAS. PTRA was technically successful in 54 (91.5%) of 59 stenotic lesions in 31 (88.6%) of 35 patients. Both aortoarteritis and FMD patients had significant decrease in RAS after PTRA. One patient had acute reocclusion of one renal artery after bilateral PTRA, which could be successfully opened by reangioplasty. Postangioplasty angiographic restudy performed in 18 patients at 4 to 72 months (mean 23.1 +/- 27.9 months) after successful angioplasty showed restenosis in 8 (25.8%) of 31 lesions initially dilated and de novo lesions of aorta in two patients. All seven restenotic renal artery lesions attempted and both stenosis of aorta were successfully dilated. Twenty-nine of 31 patients with successful PTRA have been followed up from 4 to 108 months (mean 41.0 +/- 29.3 months). Mean systolic blood pressure decreased from 185.1 +/- 27.4 to 120.6 +/- 19.2 mm Hg and mean diastolic blood pressure decreased from 118.4 +/- 13.2 to 84.6 +/- 10.4 mm Hg after PTRA. Twenty seven (93.1%) of these 29 patients had benefical blood pressure response. Seventeen (58.6%) patients improved, 10 (34.5%) were cured, although 2 (6.9%) patients failed to respond to PTRA. Blood pressure response was better in FMD as compared to aortoarteritis group. Patients with unilateral RAS, discrete stenosis, and post-PTRA stenosis < or = 20% also identified good blood pressure response.

CONCLUSION

Aortoarteritis is the most common cause of renovascular hypertension in South Asian children. PTRA is safe and highly effective and therefore should be the treatment of choice in pediatric renovascular hypertension.

Immediate and long-term results of balloon and surgical closed mitral valvotomy: a randomized comparative study

Balloon mitral valvotomy (BMV) constitutes an important alternative to surgical closed mitral valvotomy (CMV) for the treatment of rheumatic mitral stenosis. To compare the immediate and long-term results of these procedures, 200 patients with rheumatic mitral stenosis were randomly assigned to undergo either BMV (n = 100) or CMV (n = 100). The age range was 10 to 30 (mean 19.4 +/- 6.5) years. Both procedures resulted in significant and similar increases in mitral valve area (BMV: 0.85 +/- 0.26 to 2.39 +/- 0.94 cm2; CMV: 0.79 +/- 0.21 to 2.2 +/- 0.85 cm2; p = NS). Mitral regurgitation developed in 14 patients after BMV and in 12 patients after CMV. Eighty patients in each group have now been followed for a mean period of 22 +/- 6.3 (range 6 to 38) months by repeat echocardiographic study. Restenosis (defined as a loss of more than 50% of the achieved increase in mitral valve area) was seen in four (5%) patients after BMV and in three (4%) after CMV. Symptomatic restenosis was seen in only one patient who at follow-up examination 20 months after CMV had a mitral valve area of 0.8 cm2 and underwent successful balloon valvotomy. We conclude that the immediate and long-term results obtained with percutaneous BMV and surgical closed mitral commissurotomy are comparable.

Fixation of nondisplaced scaphoid fractures: making treatment cost effective. Prospective controlled trial

INTRODUCTION

Nondisplaced scaphoid waist fractures treated with prolonged plaster immobilisation often lead in transient joint stiffness and to a delay in return to sport and work activity. The long time off work increases the work off compensation costs. Internal fixation of scaphoid fractures has resulted in a shorter time to union and to return to work and sports. This prospective study compares cast immobilisation with screw fixation and the direct cost with indirect cost of conservative and minimally invasive treatment of undisplaced scaphoid fractures.

MATERIALS AND METHODS

Forty-seven patients with an acute nondisplaced waist fracture of the scaphoid were allocated into either cast immobilisation or internal screw fixation for this study. Cost data concerning the groups of nonoperated and operated patients were analysed. Range of wrist motion, grip strength, DASH-score, time to fracture union, return to work time and the needed physiotherapy at the final follow-up at 6 months were evaluated.

RESULTS

Twenty-one patients were included in the group of screw fixation and 23 patients were included in the group of cast immobilisation. At final follow-up there was no significant difference in the range of motion of the wrist or in grip strength. The operatively treated group had a better mean DASH-score than the conservative group. Fracture union was seen in the screw fixation group at a mean of 43 days and in the cast immobilisation group at a mean of 74 days (P < 0.5). The average time of return to work was 8 days for patients who had an internal screw fixation, while those treated with a cast returned to work at a mean of 55 days (P < 0.5). In total the internal fixation of undisplaced scaphoid fractures is less expensive than conservative treatment.

CONCLUSION

Internal screw fixation of nondisplaced scaphoid fractures had a shorter time to bony union and the patients returned earlier to work compared with cast immobilisation. Although it is assumed that operative treatment is more expensive, in this study the cost was not found to be higher.

Tissue distribution of lymphocytes in rheumatic heart valves as defined by monoclonal anti-T cell antibodies

Fresh cardiac valvular tissues and atrial appendages removed from 106 Indian patients with rheumatic heart disease at the time of corrective cardiac surgery were examined to determine the characteristics of valvular interstitial lymphocytic infiltrates using conventional histologic staining along with indirect immunofluorescent techniques. Precise identification of the phenotypic profiles of inflammatory mononuclear cells was attempted using anti-IgG, anti-Ia, and monoclonal mouse hybridoma reagents identifying T cells (OKT3) as well as T cell subsets (OKT4 helper/inducer and OKT8 suppressor/cytotoxic cells). A similar group of 21 patients undergoing cardiac valvular resection in Albuquerque was studied. The mean age of Indian patients providing valve tissues was 27.7, whereas in those in Albuquerque, it was 52 years. Twenty-five percent of rheumatic heart valves in Indian patients showed significant interstitial lymphoid infiltrates, and one third of the rheumatic valves from patients in Albuquerque showed similar mononuclear cell collections. Lymphoid infiltrates contained a predominance of T cells (70 to 80 percent) and only occasional B cells. Most of the T cells were OKT4-positive, with only a minor representation of suppressor/cytotoxic OKT8-positive T cells. In many instances, OKT4-positive helper T cell collections were closely juxtaposed to fibroblasts and collagen fibrils. These findings suggest that the chronic rheumatic scarring process may involve helper/inducer T cells as an ancillary factor in the indolent contracture and fibrosis of deformed cardiac valvular structures. Attempts to demonstrate residual streptococcal antigens by indirect immunofluorescence using a wide panel of heterologous rabbit F(ab')2 reagents with specificity for group A streptococcal membranes, cell wall mucopeptide, or group A carbohydrate gave negative results.

Balloon angioplasty for renovascular hypertension in Takayasu's arteritis

Percutaneous transluminal renal angioplasty was performed in 54 consecutive patients with hypertension and renal artery stenosis caused by Takayasu's arteritis. Angioplasty was technically successful in 67 (89.3%) of 75 lesions attempted. In these 67 lesions, the degree of stenosis decreased from 88.3 +/- 4.8% to 23.5% +/- 13.6% (p < 0.001) after angioplasty. Following successful angioplasty there was significant improvement in hypertension (p < 0.001) within 48 hours. Patients with bilateral renal artery stenosis had higher systolic blood pressure both before balloon dilatation (p < 0.05) and after balloon dilatation before discharge (p < 0.001), compared with patients with unilateral renal artery stenosis. Three to 70 months (mean 26.4 +/- 10.3 months) after successful angioplasty, blood pressure was reduced to normal or was improved in 93% of patients. Angiographic restudy an average of 14.2 +/- 7.8 months after angioplasty showed restenosis at the same site in 7 of 52 (13.5%) lesions and fresh stenosis in one artery. All these eight lesions were successfully dilated. Further improvement in the luminal diameter was observed in 11 (21.2%) lesions. Late angiographic restudy in seven patients an average of 56.1 +/- 6.3 months after angioplasty showed no restenosis. Our results suggest that balloon angioplasty is safe and highly effective in relieving renal artery stenosis caused by Takayasu's arteritis and should be the treatment of choice for renovascular hypertension in this disease.

Percutaneous transatrial mitral commissurotomy: immediate and intermediate results

OBJECTIVES

The purpose of this study was to evaluate the immediate and follow-up results of percutaneous transatrial mitral commissurotomy in 600 patients with rheumatic mitral stenosis.

BACKGROUND

Percutaneous transatrial mitral commissurotomy has emerged as an effective nonsurgical technique for patients with symptomatic mitral stenosis. Several studies have shown that the immediate results are comparable to closed and open mitral valvotomy.

METHODS

Percutaneous transatrial mitral commissurotomy was performed in 600 patients with rheumatic mitral stenosis by the double-balloon (290 patients [48.3%]) and flow-guided Inoue balloon (310 patients [51.7%]) techniques. There were 154 male (25.6%) and 446 female (77.4%) patients with a mean [+/- SD] age of 27 +/- 8 years (range 8 to 60). Atrial fibrillation was present in 26 patients (4.3%), mitral regurgitation < or = grade 2 in 62 (10.3%) and densely calcific valve in 12 (2%). All patients had clinical and echocardiographic (two-dimensional, continuous wave Doppler, color flow imaging) follow-up at 3-month intervals.

RESULTS

Percutaneous transatrial mitral commissurotomy was successful in 589 patients (98.1%), and optimal commissurotomy was achieved in 562 (93.6%), with an increase in mitral valve area from (mean +/- SD) 0.75 +/- 0.18 to 2.2 +/- 0.38 cm2 (p < 0.001) and a decrease in transmitral end-diastolic gradient from 27.3 +/- 6.1 to 3.8 +/- 4.2 mm Hg (p < 0.001). Mitral regurgitation developed or increased in 208 patients (34.6%). Six patients (1%) with mitral regurgitation required mitral valve replacement. Cardiac tamponade occurred in 8 patients (1.3%). Six patients (1%) died. Restenosis developed in 10 patients (1.7%) during a mean follow-up period of 37 +/- 8 months (range 6 to 66).

CONCLUSIONS

Percutaneous transatrial mitral commissurotomy is an effective, safe procedure with gratifying intermediate results. It should be considered the treatment of choice for rheumatic mitral stenosis.

Effect of ursodeoxycholic acid on bile acid metabolism in primary biliary cirrhosis

We have compared the effect of ursodeoxycholic acid with placebo on the clinical state, blood liver chemistries and serum and urinary bile acids in four patients with primary biliary cirrhosis. All parameters were evaluated monthly, and bile acid composition was measured by capillary gas-liquid chromatography. At the time of admission, all patients showed intense pruritus, and their serum alkaline phosphatase, AST and ALT levels were elevated 4.3, 2.7 and 2.3 times over control values. Serum bile acids were elevated almost 38-fold with 2.5 times more cholic acid than chenodeoxycholic acid. Urinary bile acid output was elevated 28 times the control values, and 36% were 1 beta-hydroxycholic acid, 1 beta-hydroxydeoxycholic acid and hyocholic acid (3 alpha,6 alpha, 7 alpha-trihydroxy-5 beta-cholanoic acid). Three months of placebo administration did not significantly affect the clinical or biochemical presentations, and the serum and urinary bile acid composition did not change. In contrast, ursodeoxycholic acid feeding (12 to 15 mg per kg per day) for 6 months abolished pruritus in two and lessened itching in two subjects and reduced serum alkaline phosphatase, AST and ALT levels by 21, 35 and 47%, respectively. The mean values for the total serum bile acid concentrations in these patients declined 26% from the pretreatment value, but the proportion of ursodeoxycholic acid increased from 3 to 40% of the total bile acids; thus, total fasting serum endogenous bile acid levels decreased almost 50%. Similar changes were noted in the urinary bile acids, in which ursodeoxycholic acid became the major bile acid, and approximately 18% were hydroxylated at C-1, C-6 and C-21.(ABSTRACT TRUNCATED AT 250 WORDS)

Determinants of abnormal left ventricular filling in early hypertension

Thirty-seven untreated subjects with borderline or mild hypertension were studied to establish the prevalence and clinical characteristics associated with abnormal left ventricular filling in this disorder. Subjects were referred to this study because of casual office blood pressure measurements of greater than or equal to 140/90 mm Hg; all were less than 50 years old, had no other cardiovascular or systemic disease and had not received antihypertensive medication for at least 1 year. To precisely determine blood pressure, measurements were made over 30 min with the patient in the supine position and during awake hours with ambulatory monitoring. Left ventricular mass was determined echocardiographically, and Doppler echocardiography was used to assess left ventricular filling. No subject had increased left ventricular mass, but 8 (22%) of the 37 had abnormal left ventricular filling. All eight subjects with abnormal left ventricular filling had an ambulatory systolic blood pressure greater than 130 mm Hg and a supine systolic blood pressure greater than 122 mm Hg. Abnormal filling was not related to left ventricular mass or heart rate. In multivariate analysis, the degree of abnormal filling could best be predicted from a combination of age and supine systolic blood pressure (r = 0.69; p less than 0.001). This study suggests that in untreated early essential hypertension, abnormal left ventricular filling is present in greater than 20% of subjects, precedes detectable left ventricular hypertrophy and is related to age and prevailing level of blood pressure.

Transcatheter device closure of ventricular septal defects: immediate results and intermediate-term follow-up

BACKGROUND

Transcatheter closure is an accepted mode of treatment in selected cases of congenital heart disease. Lately, this technology has been applied to closure of ventricular septal defect (VSD).

METHODS AND RESULTS

We performed percutaneous transcatheter closure of VSD in 30 patients. The location of VSD was perimembranous in 28 patients and muscular trabecular in 2. Two (7%) patients also had left ventricular-right atrial communication. There were 17 male subjects and 13 female subjects, with an age range of 5. 5 to 33 years (mean +/- SD, 12.9 +/- 5.7; median 12.2). The diameter of VSD ranged from 3 to 8 mm (mean +/- SD 4.7 +/- 1.3; median 4.5). In 5 (17%) patients, the pulmonary to systemic blood flow (Qp/Qs) was >/=2.1 (range 2.0 to 2.6). The defect was at least 6 or 8 mm from the aortic valve in patients in whom a 12- or 17-mm Rashkind double umbrella device was deployed, respectively. In 1 patient, the defect was closed with a detachable stainless steel coil, size 8 mm, with 4 loops (8 x 4). The devices were successfully deployed in 87% of patients. In 6 (20%) patients, the procedure had to be repeated primarily because of the use of undersized umbrella deices. Unsuccessful deployment of the device occurred in 4 (13%) patients. In one of these procedures, the coil embolized to the left pulmonary artery, and it was successfully retrieved. A minimal residual shunt seen as a thin streak on transthoracic color flow mapping persisted in 8 (30%) patients, which remained unchanged over a follow-up period of 5 to 28 (17.1 +/- 6.4) months. Both patients with left ventricular/right atrial communication showed complete abolition of the shunt. No patient developed new-onset aortic or tricuspid regurgitation or intravascular hemolysis. At follow-up, no patient had developed infective endocarditis, bundle branch block, or late valvular insufficiency.

CONCLUSIONS

Transcatheter closure is safe and efficacious in selected cases of perimembranous and muscular VSD.

Intrasellar tuberculoma--an enigmatic pituitary infection: a series of 18 cases

OBJECTIVE

Intrasellar tuberculomas are rare and only few case reports have been described in the literature. We report a series of 18 cases of histologically proven intrasellar tuberculomas, which, to the best of our knowledge, is the largest series in the English literature.

METHODS

A total of 1143 pituitary lesions, between 1984 and June 1999, were operated for various reasons in our institute. Of these, 18 cases were histopathologically proven intrasellar tuberculomas. The clinical profile was reviewed in detail. Radiological data and histopathological slides were also reviewed.

RESULTS

The age ranged from 8 to 43 years (average 23.6 years) with a female preponderance. The duration of symptoms varied from 15 days to 2 years (average 4 months), the most common symptoms being headache followed by decrease or loss of vision. Five patients had features of pan-hypopituitarism whereas three had raised prolactin (PRL) levels. In six patients, both sella as well as sphenoid sinus were involved. In one patient the lesion was extending from the sella over the clivus. Clinically as well as radiologically, these lesions were mistaken for pituitary adenomas except for one case where tuberculoma was suspected on imaging. In three patients, there was past history of pulmonary tuberculosis, in one patient of tuberculous meningitis, and in one patient, of spondilytis of the spine. In one patient there was cervical lymphadenopathy along with features of acromegaly (also proved by high levels of serum growth hormone) and radiology revealed a pituitary pathology. Microscopic examination of the excised lesion revealed a composite lesion consisting of a pituitary adenoma and tuberculoma, which has not been documented in literature to date. One patient died during the hospital stay. All the other patients were put on antitubercular chemotherapy following surgery and had good outcomes.

CONCLUSION

Intrasellar tuberculomas are rare. These may be suspected in female patients especially if radiological imaging shows involvement of paranasal sinuses and pituitary fossa along with thickening of pituitary stalk. Simultaneous involvement of clivus may also be an additional feature. The incidence of pituitary tuberculosis is likely to increase with a rise in the incidence of AIDS.

Amniotic membrane transplantation in acute chemical burns

PURPOSE

To evaluate the outcome of fresh amniotic membrane transplantation (AMT) for ocular surface reconstruction in acute chemical burns.

METHODS

A prospective study of 15 consecutive eyes with acute chemical burns was performed. In all, 10 eyes had lime burns and five eyes had acid burns. There were three eyes of grade II, four eyes of grade III and eight eyes of grade IV burns. AMT was performed within 3 weeks of injury.

RESULTS

Patients were followed up for 10.14 +/- 4.41 months. All patients had immediate relief of pain postoperatively. Of 15 eyes, nine (60%) showed epithelialization within 1-4 weeks (15.33 +/- 9.91 days). The final visual acuity improved in 10 of 15 eyes (66.66%). Eyes with burns of grade II and III showed more visual improvement than those with grade IV burns. None of the eyes showed perforation. Symblepharon was seen in nine of 15 eyes (60%). Of 15 eyes, 12 (80%) experienced limbal stem cell deficiency and showed superficial corneal vascularization.

CONCLUSIONS

Amniotic membrane transplantation with fresh amniotic membrane increases patient comfort and reduces inflammation. In mild burns, AMT alone restores corneal and conjunctival surfaces. In moderate to severe burns, it probably reduces conjunctival scarring sequelae, but does not prevent the sequelae of limbal stem cell deficiency that requires further limbal stem cell transplantation. In the acute stage, amniotic membrane transplantation probably has a protective role against the progressive melting and perforation.

Palmar locking plate for treatment of unstable dorsal dislocated distal radius fractures

INTRODUCTION

This study investigates the clinical and radiological results of open reduction and internal fixation of unstable distal radial fractures using a palmar placed interlocking plate system with no substitutes for treatment of the dorsal metaphyseal fracture void.

MATERIALS AND METHODS

Nineteen patients with a mean age of 61 years (range 49-78 years) and a dorsally displaced distal radial fracture were treated using a palmar placed 2.4 mm interlocking plate system. All 17 women and 2 men were followed up according to the study protocol. Standardised radiographs in anteroposterior and lateral projection were performed before reduction and at 2, 6, 12 and 24 weeks after surgery. Radiological measurements included palmar tilt, radial inclination and radial shortening as defined by ulnar variance and intra-articular steps. Clinical assessment included active range of motion (ARM) of the wrist, pain according to a visual analogue scale (VAS), grip power, working ability, Disability of Arm, Shoulder and Hand-Score (DASH Score) and Mayo Wrist Score.

RESULTS

At final follow-up after a minimum of 11 months, the palmar tilt was +1 degrees , radial inclination 19.8 degrees and ulnar variance 1.0 mm. Mean loss of palmar tilt measured 1.9 degrees , radial inclination 1.3 degrees and ulnar variance 0.4 mm. Mean wrist extension measured 58 degrees , wrist flexion 41 degrees , pronation 83 degrees and supination 84 degrees . The Mayo Wrist Score showed 21% excellent, 58% good, 16% fair and 5% poor results.

CONCLUSION

The treatment of unstable, dorsally dislocated, distal radius fractures AO types A3, C1 and C2, with a palmar placed 2.4 mm interlocking plate system and without additional treatment of the metaphyseal defects showed good radiological and functional results with minimal loss of reduction.

Intramedullary tuberculoma of the spinal cord: a series of 10 cases

OBJECTIVE

Involvement of vertebral column is common in tuberculosis but intramedullary tuberculomas are rare. We report a series of ten cases of intramedullary tuberculomas, which, to the best of our knowledge, is the largest series of biopsy proven intramedullary tuberculomas in English literature.

METHODS

During a period of 16 years (1985-2000), ten cases of intramedullary tuberculomas were diagnosed in our department. Of these, eight cases were histologically proven intramedullary tuberculomas. The clinical profile, radiological data and histological slides were reviewed.

RESULTS

Age ranged from 18 to 45 years (mean 29.7 years) and there was slight male preponderance (six men, four women). Duration of symptom varied from 3 to 20 months (mean 11.5 months). All of them presented with motor weakness and sensory impairment. Most common site of involvement was dorsal cord followed by cervical, cervicodorsal and dorsolumbar regions. Three patients had associated involvement of lungs, cervical lymphnodes, and brain, and one patient had past history of tuberculous meningitis. Two patients were treated conservatively but surgical excision was done in eight cases followed by medical treatment.

CONCLUSION

Radiologically, intramedullary tuberculomas should be differentiated from other space occupying lesions (SOL) to avoid unnecessary surgery especially in those patients with tuberculosis of the other organs. The incidence of intramedullary tuberculomas is likely to increase with a rise in the incidence of AIDS.

Cutaneous complications of hepatic chemoembolization via extrahepatic collaterals

PURPOSE

To report cutaneous complications occurring after chemoembolization of hepatic tumors via extrahepatic collaterals.

METHODS

Five patients underwent chemoembolization via the internal mammary (n = 3), intercostal (n = 1), or multiple extrahepatic collateral vessels supplying liver metastases.

RESULTS

Painful induration and discoloration of the skin in the distribution of the superior epigastric or intercostal arteries occurred in four patients, with transmural necrosis in two. One required surgical excision. One patient developed a radiation burn after 12 procedures and eventually developed a squamous cell carcinoma at the site, which required resection and skin grafting.

CONCLUSION

Cutaneous injury can occur after chemoembolization of extrahepatic collaterals. Scrupulous technique is required to avoid nontarget embolization of chemotherapeutic drugs. High cumulative radiation doses to localized areas of skin can occur in patients undergoing multiple procedures.

Balloon angioplasty of the aorta in Takayasu's arteritis: Initial and long-term results

Percutaneous transluminal balloon angioplasty for stenosis of the aorta was performed in 36 patients with Takayasu's arteritis (age range, 8 to 36 years; mean, 19.1 +/- 7.7 years). Balloon dilatation was successful in 34 patients and resulted in a decrease in the mean peak systolic pressure gradient (PSG) from 75.2 +/- 29.1 mm Hg to 24.8 +/- 19 mm Hg (p less than 0.001) and a mean increase in the diameter of the stenosed segments from 4.5 +/- 2.2 mm to 9.6 +/- 3.8 mm (p less than 0.001). Hemodynamic and angiographic restudy, which was performed in 20 patients at a mean follow-up period of 7.7 +/- 4.1 months (range, 3 to 24 months), showed a further decrease in PSG (greater than or equal to 15 mm Hg) in seven patients (from 40.0 +/- 11.2 mm Hg to 15.7 +/- 10.2 mm Hg; p less than 0.01), no significant change in PSG in 12 patients (17.1 +/- 13.6 mm Hg vs 16.6 +/- 12.7 mm Hg; p = NS), and an increase in PSG from 15 mm Hg to 85 mm Hg in one patient. The patient who showed restenosis underwent successful redilatation. Six patients who underwent late recatheterization and angiography at 36 to 60 months (mean, 43 +/- 9.4 months) show continued relief of stenosis (mean PSG, 8.8 +/- 7.8 mm Hg). Patients with short-segment (less than 4 cm) stenosis experience more relief than patients with long-segment (greater than or equal to 4 cm) stenosis (residual PSG, 18.6 +/- 8.2 mm Hg vs 40 +/- 16 mm Hg; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)