Serial cervical-length measurements after first episode of threatened preterm labor improve prediction of spontaneous delivery prior to 37 weeks' gestation.

OBJECTIVE: To assess whether repeat cervical-length (CL) measurement in women discharged from hospital after their first episode of threatened preterm labor can predict their risk of spontaneous preterm birth. METHODS: This was a secondary analysis of a randomized controlled trial of maintenance tocolysis, in which CL was measured on transvaginal ultrasound at the time of hospital discharge and after 2, 4, 8 and 12 weeks, in women who remained undelivered after their first episode of threatened preterm labor. After univariate analysis, multivariate logistic regression analysis was used to assess whether CL < 10 mm at the time of hospital discharge or at any follow-up evaluation could predict spontaneous delivery prior to 37 weeks of gestation. RESULTS: Of 226 women discharged after a diagnosis of threatened preterm labor, 57 (25.2%) delivered spontaneously prior to 37 weeks' gestation. The risk of spontaneous preterm birth was higher among women with CL < 10 mm at hospital discharge compared to those with CL ≥ 10 mm (adjusted odds ratio (aOR), 3.3; 95% CI, 1.2-9.2). Moreover, spontaneous preterm delivery was more common when CL < 10 mm was detected up to 2 weeks (aOR, 2.9; 95% CI, 1.1-7.3) or up to 4 weeks (aOR, 7.3; 95% CI, 2.3-22.8) post discharge, as compared with when CL was persistently ≥ 10 mm. The association was not significant when considering CL measurements at 8 weeks, and there was insufficient information to assess the effect of measurements obtained at 12 weeks. CONCLUSIONS: Women who remain undelivered after their first episode of threatened preterm labor continue to be at high risk of spontaneous preterm birth if their CL is below 10 mm at the time of hospital discharge or at any follow-up visit up to 4 weeks later. CL measurement could be included in the antenatal care of these women in order to stratify their risk of preterm birth, rationalize resource utilization and help clinicians improve pregnancy outcome. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Pro-inflammatory mediators in vaginal fluid and short cervical length in pregnancy.

AIM: We hypothesized that elevated vaginal levels of matrix metalloproteinase-8 (MMP-8), interleukin-8 (IL-8) and the 70kDa heat shock protein (hsp70), compounds involved in inflammatory responses, correlated with a short cervix in pregnant women. METHODS: This prospective cohort study used a convenience sample of 64 women in their early third trimester with a singleton pregnancy. A short cervical length was present in 35 women (54.7 %). Vaginal fluid was tested for levels of MMP-8, IL-8 and hsp70 by enzyme-linked immunosorbent assay (ELISA). A receiver operating charasteristic (ROC) analysis was used to calculate the area under the curve (AUC) for each mediator in predicting short cervical length. RESULTS: MMP-8 (109 vs 29.6 ng/ml, p=0.014), IL-8 (689 vs 330 pg/ml, p=0.007) and hsp70 (4.4 vs 2.9 ng/ml, p=0.036) were all elevated in vaginal samples from women with a short cervix. In addition, there was a negative association between the concentration of each compound in vaginal fluid and cervical length p≤0.026). The vaginal IL-8 concentration had the highest negative correlation with a short cervix (AUC=0.7, p=0.007). CONCLUSION: MMP-8, hsp70 and IL-8 contribute to a pro-inflammatory cervico-vaginal milieu that weakens cervical integrity and leads to a shortening in cervical length (Tab. 4, Fig. 1, Ref. 27).

Management of cytomegalovirus infection in pregnancy: is it time for valacyclovir?

BACKGROUND: Congenital cytomegalovirus (CMV) infection is the leading infectious cause of neurological impairment for which, currently, there are no approved antenatal treatment options. OBJECTIVES: The aim of this article was to summarize the available evidence on the use of valacyclovir during pregnancy to prevent and treat congenital CMV infection and disease. SOURCES: Two databases (PubMed and ClinicalTrial.gov) were reviewed. CONTENT: Six relevant documents were identified, namely one observational study, three clinical trials, two case reports. Most relevant findings were those from two clinical trials. A phase 2/3 placebo-controlled study showed a decrease of 71% (5 of 45 vs 14 of 47) in rate of CMV vertical transmission in women treated with 8 g/day valacyclovir following primary CMV infection in pregnancy. A phase 2, single-arm clinical trial, showed that 8 g/day valacyclovir administered to mothers of symptomatic infected foetuses increased the portion of asymptomatic neonates to 82% (34 of 41), compared with 43% (20 of 47) in untreated pregnancies from a historical cohort. IMPLICATIONS: Studies in favour of using valacyclovir during pregnancy for prevention and treatment of congenital CMV infection are emerging but are still few. Randomized clinical trials on large cohorts of patients investigating the efficacy on prevention and treatment of congenital CMV are required. Unfortunately, this will be probably not be feasible at least in the short period. In the meantime, data on the 'off label' use of valacyclovir for CMV in pregnancy could be collected within a multicentre observational study.

Reproducibility of rectal tumor volume delineation using diffusion-weighted MRI: Agreement on volumes between observers.

PURPOSE: To retrospectively evaluate the inter-observer agreement between a radiologist and a radiation oncologist and volume differences, in T2 and diffusion-weighted (DWI) MRI of gross tumor volume (GTV) delineation, in rectal cancer patients. MATERIALS AND METHODS: Two observers, a radiologist and a radiation oncologist, delineated GTVs of 50 patients on T2-weighted MRI (T2GTV) and echo planar DWI (DWIGTV). Observers agreement was assessed using DICE index, Bland-Altman analysis and intra-class correlation coefficient (ICC). Student's t-test was used for GTV comparison. RESULTS: Median T2GTV and DWIGTV were 17.09±14.12 cm3 (1.92-62.03) and 12.79±12.31 cm3 (1.23-62.25) for radiologist, and 16.82±13.66 cm3 (1.78-65.9) and 13.72±12.77 cm3 (1.29-69.75) for radiation oncologist. T2GTV were significantly larger compared to DWIGTV (P<0.001 and P<0.001, for both observers). Mean DICE index for T2GTV and DWIGTV were 0.80±0.07 and 0.77±0.06. The mean difference between the two observers were 0.26cm3 (95% CI: -5.36 to 5.88) and -1.13cm3 (95% CI: -5.70 to 3.44) for T2 and DWI volumes. The ICC for T2 volumes was 0.989 (95% CI: 0.981-0.994) (P<0.001) and 0.992 (95% CI: 0.986-0.996) (P<0.001) for DWI volumes. CONCLUSION: DWI resulted in smaller volumes delineation compared to T2-weighted MRI. Substantial and almost perfect agreements were reported for DWIGTV and T2GTV between radiologist and radiation oncologist. Due to the fact that DWI could be considered a simple technique for volume delineation for radiation oncologist, DWI could be used to improve quality in radiation planning for an accurate boost volume delineation when a dose escalation is investigated.

Hippocampal sparing in stereotactic radiotherapy for brain metastases: To contour or not contour the hippocampus?

PURPOSE: The aim of our study was to evaluate hippocampal irradiation in patients treated with fractionated stereotactic brain radiotherapy. PATIENTS AND METHODS: Retrospective hippocampal dosimetric analysis performed on 22 patients with one to four brain metastases treated with fractionated stereotactic radiotherapy using volumetric intensity-modulated arc therapy. Original plans did not include hippocampus as avoidance structure in optimization criteria; hippocampus was retrospectively delineated on magnetic resonance coregistered with planning CT and using as reference the RTOG 0933 atlas. Hippocampus was defined both as a single and as pair organ. Constraints analysed were: Dmax<16Gy, D40%<7.3Gy, D100%=Dmin<9Gy. Assuming a α/ß ratio of 2Gy, biologically equivalent dose in 2Gy fractions was calculated. Hippocampal-sparing plans were developed in cases where hippocampal constraints were not respected in the original plan. RESULTS: Among constraints analysed Dmax and D40% have been exceeded in ten out of 22 cases. The constraints were not respected in patients with more than one metastatic lesion and in three patients with only one lesion. Considering all exceeded constraints values in non-hippocampal sparing plans, the 50% of them was respected after replanning. No significant differences were found among conformity and homogeneity index between non-hippocampal sparing and hippocampal sparing plans. CONCLUSION: Volumetric intensity-modulated arc therapy hippocampal sparing plans significantly decreases dose to hippocampus assuring an equal target coverage and organs at risk avoiding.

Placental and maternal serum activin A in spontaneous and induced labor in late-term pregnancy.

PURPOSE: Feto-placental unit represents an important source of activin A, a member of transforming growth factors-ß involved in the mechanisms of labor. No evidences are available on activin A in pregnancies beyond 41 weeks of gestation, where induction of labor is often required. The present study aimed to evaluate activin A maternal serum levels and placental mRNA expression in term and late-term pregnancy, with spontaneous or induced labor, and its possible role to predict the response to labor induction. METHODS: Maternal serum samples and placental specimens were collected from women with singleton pregnancy admitted for either term spontaneous labor (n = 23) or induction of labor for late-term pregnancy (n = 41), to evaluate activin A serum levels and placental mRNA expression. Univariate and multivariate analyses on activin A serum levels, maternal clinical parameters, and cervical length were conducted in women undergoing induction of labor. RESULTS: Maternal serum activin A levels and placental activin A mRNA expression in late-term pregnancies were significantly higher than at term. Late-term pregnancies who did not respond to induction of labor showed significantly lower levels of activin A compared to responders. The combination of serum activin A and cervical length achieved a sensitivity of 100% and a specificity of 93.55% for the prediction of successful induction. CONCLUSION: Late-term pregnancy is characterized by hyperexpression of placental activin A and increased maternal activin A secretion. By combining maternal serum activin A levels with cervical length, a good predictive model for the response to induction of labor was elaborated.

Occiput-spine relationship: shoulders are more important than head.

OBJECTIVE: To understand the role of fetal spine position in determining a fetal head position at the time of birth and modality of delivery. PATIENTS AND METHODS: This was a multicenter prospective observational study. Fetal occiput and spine position were evaluated by intrapartum ultrasound. Eighty-six women were eligible for inclusion in the study. Occiput rotational movements and modality of delivery in relation to the fetal spine position were investigated. RESULTS: At the beginning of labor, fetal occiput was in a posterior position in 52.3% of cases and, in 81.5% of cases the spine was in an anterior transverse position. At birth, occiput and spine were both in an anterior position in 90.4% of cases. The rate of cesarean sections in the SP group was significantly higher than the rate in the SAT group (50% vs. 8%, p < 0.0007). Instead, the rate of vaginal deliveries without intervention in the SP group was significantly lower than the rate in the SA group (14% vs. 71%, p < 0.0001). CONCLUSIONS: Fetal spine position could have an important role in determining fetal occiput position at birth. Spine position might play a crucial role in the outcome of delivery.

Analysis of the main risk factors for gestational diabetes diagnosed with International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria in multiple pregnancies.

INTRODUCTION: The aim is to investigate the proportion of multiple pregnancies with gestational diabetes mellitus (GDM) diagnosed using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria and to identify the impact of age, body mass index (BMI), and mode of conception on incidence of GDM. MATERIALS AND METHODS: This is a single center, retrospective cohort study on 656 multiple pregnancies screened for GDM with 75-g, 2-h oral glucose tolerance test at 24-28 weeks of gestation, between January 2010 and January 2016. The diagnosis of gestational diabetes mellitus (GDM) was reached through the IADPSG. RESULTS: The incidence of GDM in our population was 15.1%. When patients who conceived through heterologous assisted reproduction technology were compared with those who conceived spontaneously, there was a significant difference for GDM (31.1 vs 13.6%, p < 0.001, OR 2.86). A similar finding was also observed comparing egg donation IVF/ICSI patients with homologous IVF/ICSI patients (31.1 vs 14.8%, p = 0.006, OR 2.59). Incidence of GDM was significantly higher in obese than in non-obese patients (42.5 vs 14.8%, p < 0.001, OR 4.88) and in women over 35 compared to younger patients (18.4 vs 11.1%, p = 0.01, OR 1.81). Logistic regression comparing the diabetes onset with conception mode gave a p = 0.07. The calculation of the Chi-square and odds ratio for single mode of conception showed that homologous vs conceived spontaneously p = 0.90, OR 0.97, heterologous vs homologous p = 0.01 with OR 2.46, and heterologous vs conceived spontaneously p = 0.01 with OR 2.39. Logistic regression showed that age and BMI are risk factors for developing GDM, respectively, p = 0.03 with OR 1.4 and p < 0.01 and OR 1.09. DISCUSSION: The contribution our study can make is improved counseling about GDM risks for couples with multiple pregnancies. Our data support the role of age, BMI, and mode of conception as risk factors for GDM in multiple pregnancies.

Induction of labour for suspected macrosomia at term in non-diabetic women: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Several randomized controlled trials (RCTs) compared induction of labour with expectant management in non-diabetic women with suspected fetal macrosomia. OBJECTIVE: To evaluate the effects of labour induction for suspected fetal macrosomia. SEARCH STRATEGY: Literature search in electronic databases. SELECTION CRITERIA: We included all RCTs of suspected fetal macrosomia comparing labour induction with expectant management in term pregnancy. DATA COLLECTION AND ANALYSIS: The primary outcome was the incidence of caesarean delivery. MAIN RESULTS: Four RCTs, including 1190 non-diabetic women with suspected fetal macrosomia at term, were analysed. Pooled data did not show a significant difference in incidence of caesarean delivery [relative risk (RR) 0.91, 95% confidence interval (CI) 0.76-1.09], operative and spontaneous vaginal delivery, shoulder dystocia, intracranial haemorrhage, brachial plexus palsy, Apgar score <7 at 5 min, cord blood pH <7, and mean birth weight comparing women who received induction of labour with those who were managed expectantly. The induction group had a significantly lower time to delivery (mean difference -7.55 days, 95% CI -8.20 to -6.89), lower rate of birth weight ≥4000 g (RR 0.50, 95% CI 0.42-0.59) and ≥4500 g (RR 0.21, 95% CI 0.11-0.39), and lower incidence of fetal fractures (RR 0.17, 95% CI 0.03-0.79) compared with expectant management group. CONCLUSION: Induction of labour ≥38 weeks for suspected fetal macrosomia is associated with a significant decrease in fetal fractures, and therefore can be considered as a reasonable option. TWEETABLE ABSTRACT: #Induction of labour for #macrosomia improves neonatal outcome.

Prevalence of a positive TORCH and parvovirus B19 screening in pregnancies complicated by polyhydramnios.

OBJECTIVE: The aim of this study was to evaluate the rate of women with polyhydramnios who eventually screened positive to infectious disease by serum screening testing for TORCH and parvovirus B19. METHODS: This is a retrospective observational study on singleton pregnancies with a diagnosis of polyhydramnios and who had serum screening for TORCH and parvovirus B19. Patients were followed with serial ultrasounds between 2006 and 2013. Maternal characteristics, medical and obstetric history were reviewed. Ultrasound parameters, including amniotic fluid index and fetal anomalies, and the results of serologic tests were reviewed. RESULTS: Two hundred ninety patients met the inclusion criteria. Of these, 56 (19%) presented one of the following pathological conditions associated with polyhydramnios: diabetes (13% of total cases), obstructive gastrointestinal lesions (5%), Rhesus isoimmunization (0.3%), chromosomal abnormalities or genetic syndromes (1%). Among the remaining 234 patients, only three had a positive test result for infectious disease (1%, 95% Confidence Interval (CI) 0-4%): two women were positive for parvovirus B19 and one for toxoplasmosis infection. In none of them the fetus was affected, as confirmed by serum testing after birth and by 3 years follow-up. CONCLUSIONS: Infectious disease screening does not seem beneficial in pregnancies with isolated polyhydramnios.

Anterior placental location influences onset and progress of labor and postpartum outcome.

INTRODUCTION: The aim of the study is to evaluate whether placental location at term is associated with delivery outcome. METHODS: A prospective study including 2354 patients with singleton pregnancy at term admitted for vaginal delivery was conducted. Placental position was determined before delivery by ultrasonographic examination performed transabdominally with women in the supine position. Maternal characteristics and delivery outcome such as premature rupture of membranes, induction of labor, mode and gestational age at delivery, indication for cesarean section, duration of the third stage, postpartum hemorrhage (PPH) and manual removal of placenta were correlated with anterior, posterior or fundal placental locations. RESULTS: Among women enrolled: i) 1164 had an anterior placenta, ii) 1087 a posterior placenta, iii) 103 a fundal placenta. Women with anterior placenta showed: i) a higher incidence of induction of labor (p = 0.0001), especially for postdate pregnancies and prolonged prelabor rupture of membranes (p < 0.0001), ii) a higher rate of cesarean section rate for failure to progress in labor (p = 0.02), iii) a prolonged third stage (p = 0.01), iv) a higher incidence of manual removal of placenta (p = 0.003) and a higher rate of PPH in vaginal deliveries (p = 0.02). DISCUSSION: The present study showed the influence of anterior placental location on the course of labor, with a later onset of labor, a higher rate of induction and cesarean section and postpartum complications. The reason for this influence on labor and delivery complications remains to be elucidated.

Interobserver variability of clinical target volume delineation in soft-tissue sarcomas.

PURPOSE: The present observational study reports the results of a multi-institutional dummy-run designed to estimate the consistency of interobserver variability in clinical target volume delineation in two different cases of soft-tissue sarcomas in which postoperative and preoperative radiotherapy were prescribed, respectively. The purpose of this work was to quantify interobserver variability in routine clinical practice. PATIENTS AND METHODS: Two different cases of soft-tissues sarcomas were chosen: a case of postoperative and a case of preoperative radiation therapy. Participating centres were requested to delineate clinical target volumes according to their experience in both cases. Descriptive statistic was calculated for each variable (volume, diameters) separately for two cases. Box-whiskers plots were used for presentation of clinical target volume. A Shapiro-Wilk's test was performed to evaluate the departures from normality distribution for each variable. The comparison between relative variations of diameters was evaluated using the Student's t test. RESULTS: Several variations affecting both volumes and diameters were observed. Main variations were observed in the craniocaudal and laterolateral diameters. Each case showed similar dispersion, indicating a lack of reproducibility in volumes definition. CONCLUSIONS: This observational study highlighted that, in the absence of specific instructions or guidelines, the interobserver variability can be significant both in postoperative and preoperative radiotherapy of soft-tissue sarcomas.

Diffusion-weighted magnetic resonance for prediction of response after neoadjuvant chemoradiation therapy for locally advanced rectal cancer: preliminary results of a monoinstitutional prospective study.

PURPOSE: To evaluate diffusion-weighted imaging (DWI) for assessment of treatment response in locally advanced rectal cancer (LARC) 8 weeks after neoadjuvant chemoradiotherapy (CRT). METHODS AND MATERIALS: A total of 28 patients with LARC underwent magnetic resonance imaging (MRI) prior to and 8 weeks after CRT. Tumor volume (TV) was calculated on T2-weighted MRI scans as well as the apparent diffusion coefficient (ADC) was calculated using Echo-planar DWI-sequences. All data were correlated to surgical results and histopathologic tumor regression grade (TRG), according to Mandard's classification. Post-treatment difference ADC (%ΔADC) and TV (%ΔTV) changes at 8 weeks were compared complete response (CR; TRG1) and non-complete response tumors (non-CR; TRG2-5). RESULTS: The mean % ADC increase of CR group was significantly higher compared to non-CR group (77.2 ± 54.63% vs. 36.0 ± 29.44%; p = 0.05). Conversely, the mean % TV reduction did not significantly differ in CR group from non-CR group (73.7% vs. 63.77%; p = 0.21). Accordingly, the diagnostic accuracy of the mean % ADC increase to discriminate CR from non-CR group was significantly higher than that of the mean % TV reduction (0.913 vs. 0.658; p = 0.022). No correlation was found between mean % TV reduction and TRG (rho = 0.22; p = 0.3037), whereas a negative correlation between mean % ADC increase and TRG was recorded (r = -0.69; p = 0.006). CONCLUSION: The mean % ADC increase appears to be a reliable tool to differentiate CR from non-CR after CRT in patients with LARC.

Stillbirth and fetal growth restriction.

OBJECTIVE: To confirm the role of fetal growth restriction (FGR) as a cause of stillbirth, and to compare diagnostic accuracy of customized fetal growth and population-based standards in identifying FGR within a pathological population of early and late stillbirths. METHODS: Retrospective study on a cohort of 189 stillbirths occurred in single pregnancy between January 2006 and September 2011. Unexplained stillbirths, defined by Aberdeen-Wigglesworth and ReCoDe classifications, were evaluated on the basis of fetal birthweight with both Tuscany population and Gardosi customized standards. Unexplained stillbirths have been classified as early or late depending on the gestational age of occurrence. RESULTS: Aberdeen-Wigglesworth classification, applied to the 189 cases of stillbirth, left 94 unexplained cases (49.7%), whereas the ReCoDe classification left only 40 (21%). By applying population standards to the 94 unexplained stillbirths we have identified 31 FGRs (33% of sample), while customized standards identified 54 FGRs (57%). Customised standards identified a larger number of FGRs with respect to population standards during the third trimester (i.e. 51% vs. 25% respectively) than in the second trimester (73% vs. 54% respectively) (p = 0.05). CONCLUSIONS: Customized standards have a higher diagnostic accuracy in identifying FGRs especially during the third trimester.

Clinical use of placental hormones in pregnancy management.

Across human pregnancy, placenta represents a transit of oxygen and nutrients from the mother to the fetus and actively produces a large number of hormones that serve to regulate and balance maternal and fetal physiology. An abnormal secretion of placental hormones may be part of the pathogenesis of the main obstetric syndrome, from early to late pregnancy, in particular chromosomopathies, miscarriage, gestational trophoblastic diseases, preeclampsia, gestational diabetes, and pre-term delivery. The possibility to measure placental hormones represents an important tool not only for the diagnosis and management of gestational disorders, but it is also fundamental in the early identification of women at risk for these pregnancy complications. In the last decades, the use of ultrasound examination has provided additional biophysical markers, improving the early diagnosis of gestational diseases. In conclusion, while few placental hormones have sufficient sensitivity for clinical application, there are promising new biochemical and biophysical markers that, if used in combination, may provide a valid screening tool.

A comparative study of bipolar disorder and attention deficit hyperactivity disorder through the measurement of regional cerebral blood flow.

Attention Deficit Hyperactivity Disorder (ADHD) and Bipolar Disorder (BPD) are two common neuropsychological disorders which are often present in a comorbid state. I used the results of cerebral blood flow studies made with Single Photon Emission Computer Tomography (SPECT), Positron Emission Tomography (PET) and Functional Magnetic Resonance Imaging (fMRI), to investigate a possible relationship between ADHD and BPD. The common areas of the brain involved in both BPD and ADHD appears to be the prefrontal cortex in its various components, the basal ganglia and possibly the cerebellum which, especially in the past, has been little studied by researchers in relation to ADHD and BPD. Among the differences the blood flow lateralization, present in BPD in states of altered mood, is evident with left hypoperfusion and right hyperperfusion during depression, the opposite in the case of manic state; in ADHD, the lateralization is less constant and of questionable interpretation. In BPD the involvement of a greater number of brain areas, especially the temporal lobe, is common. I advance the hypothesis that BPD progresses from ADHD secondary to expansion of perturbation in cerebral blood flow.

[Identification of preterm labor: the role of the fibronectin and ultrasound cervicometry and their association]. / La identificazione del travaglio pretermine: ruolo della fibronectina e della cervicometria ecografica e loro associazione.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of the fetal fibronetcin (fFN) test and ultrasonographic cervical length measurement used alone or in combination with each other in order to further improve the identification of patients in preterm labor. METHODS: Prospective multicenter observational study on patients between 24 and 32 weeks of gestation with symptoms of preterm labor (total patients = 132). The endpoint was the delivery at 34 weeks or more. The screening methods used were: the fFN test (group 1), the cervical length measurement by transvaginal ultrasound (group 2) or a combination of both tests (group 3) according to an established protocol. The statistical analysis was performed using the χ2 test using the SPSS software. RESULTS: Group 1: positive fFN test in 25.7% of cases, incidence of preterm birth (<34 weeks) of 18%. Group 2: cervical length <25 mm in 56.2% of cases, incidence of preterm birth (<34 weeks) of 18.5%. The negative predictive value is equivalent to 99.0% for the fFN test and 95.2% for cervicometry; combined use reaches 100%, compared to 54% positive predictive value. CONCLUSION: The identification of women at high risk of preterm delivery carried out with the fFN test or with transvaginal ultrasound cervicometry is clinically valid. The study also showed that the contextual use of biochemical and biophysical tests reaches a high negative predictive value (100%), making it a very useful method to identify patients truly at risk and to further reduce the incidence of non adequate treatment.

Chagas disease in Italy: breaking an epidemiological silence.

Chagas disease, a neglected tropical disease that due to population movements is no longer limited to Latin America, threatens a wide spectrum of people(travellers, migrants, blood or organ recipients,newborns, adoptees) also in non-endemic countries where it is generally underdiagnosed. In Italy, the available epidemiological data about Chagas disease have been very limited up to now, although the country is second in Europe only to Spain in the number of residents from Latin American. Among 867 at-risk subjectsscreened between 1998 and 2010, the Centre for Tropical Diseases in Negrar (Verona) and the Infectious and Tropical Diseases Unit, University of Florence found 4.2% patients with positive serology for Chagas disease (83.4% of them migrants, 13.8% adoptees).No cases of Chagas disease were identified in blood donors or HIV-positive patients of Latin American origin. Among 214 Latin American pregnant women,three were infected (resulting in abortion in one case).In 2005 a case of acute Chagas disease was recorded in an Italian traveller. Based on our observations, we believe that a wider assessment of the epidemiological situation is urgently required in our country and public health measures preventing transmission and improving access to diagnosis and treatment should be implemented.

Serum cardiac troponin I concentration in dogs with precapillary and postcapillary pulmonary hypertension.

BACKGROUND: Pulmonary hypertension (PH) is a disease condition leading to right-sided cardiac hypertrophy and, eventually, right-sided heart failure. Cardiac troponin I (cTnI) is a circulating biomarker of cardiac damage. HYPOTHESIS: Myocardial damage can occur in dogs with precapillary and postcapillary PH. ANIMALS: One hundred and thirty-three dogs were examined: 26 healthy controls, 42 dogs with mitral valve disease (MVD) without PH, 48 dogs with pulmonary hypertension associated with mitral valve disease (PH-MVD), and 17 dogs with precapillary PH. METHODS: Prospective, observational study. Serum cTnI concentration was measured with a commercially available immunoassay and results were compared between groups. RESULTS: Median cTnI was 0.10 ng/mL (range 0.10-0.17 ng/mL) in healthy dogs. Compared with the healthy population, median serum cTnI concentration was increased in dogs with precapillary PH (0.25 ng/mL; range 0.10-1.9 ng/mL; P < .001) and in dogs with PH-MVD (0.21 ng/mL; range 0.10-2.10 ng/mL; P < .001). Median serum cTnI concentration of dogs with MVD (0.12 ng/mL; range 0.10-1.00 ng/mL) was not significantly different compared with control group and dogs with PH-MVD. In dogs with MVD and PH-MVD, only the subgroup with decompensated PH-MVD had significantly higher cTnI concentration compared with dogs with compensated MVD and PH-MVD. Serum cTnI concentration showed significant modest positive correlations with the calculated pulmonary artery systolic pressure in dogs with PH and some echocardiographic indices in dogs with MVD and PH-MVD. CONCLUSIONS AND CLINICAL IMPORTANCE: Serum cTnI is high in dogs with either precapillary and postcapillary PH. Myocardial damage in dogs with postcapillary PH is likely the consequence of increased severity of MVD.

Evaluation of a portable meter to measure ketonemia and comparison with ketonuria for the diagnosis of canine diabetic ketoacidosis.

BACKGROUND: The diagnosis of canine diabetic ketoacidosis (DKA) usually is based on measurement of urinary acetoacetate (ketonuria). In humans, this test is less sensitive and specific than blood 3-beta-hydroxybutyrate (ketonemia) evaluation. HYPOTHESIS: Ketonemia measurement using a portable meter is more accurate than ketonuria determination with a dipstick to diagnose canine DKA. ANIMALS: Seventy-two client-owned diabetic dogs with ketonemia, ketonuria, or both. METHODS: Prospective observational study. Based on blood bicarbonate concentration and anion gap, dogs were divided into 2 groups: patients with DKA (n= 25); patients with diabetic ketosis (n= 47). Sensitivity, specificity, and positive and negative likelihood ratio (LR) at different cut-off points were determined for both ketonemia and ketonuria. Receiver operating characteristic (ROC) analysis was used to assess the accuracy of each diagnostic test to diagnose DKA. RESULTS: With regard to ketonemia, cut-off values of 2.3 and 4.3 mmol/L revealed 100% sensitivity and 100% specificity, respectively, whereas cut-off values of 2.8 and 3.5 mmol/L showed a -LR of 0.05 and a + LR of 13.16, respectively. With regard to ketonuria, a cut-off value of 1+ revealed 92% sensitivity, 40% specificity, and -LR of 0.20, whereas a cut-off value of 3+ revealed 44% sensitivity, 94% specificity, and +LR of 6.89. The areas under the ROC curves for the ketonemia and ketonuria tests were significantly different (0.97 and 0.81, respectively, P= .003). CONCLUSIONS AND CLINICAL IMPORTANCE: Measurement of ketonemia is accurate and more effective than measurement of ketonuria to diagnose canine DKA.