Effectiveness and safety of medium-dose prednisone in giant cell arteritis: a retrospective cohort study of 103 patients.

OBJECTIVES: To compare the effectiveness and safety of medium-dose (MD) and high-dose (HD) prednisone regimens and to identify factors related to remission with a target maintenance dose of prednisone in patients with giant cell arteritis (GCA). METHODS: Retrospective cohort study conducted in an autoimmune diseases unit. Patients received ≤ 30 mg (MD group) or >30 mg (HD group) of daily prednisone as monotherapy or combined with methylprednisolone pulses and/or methotrexate, at the discretion of the physician. The primary endpoint was time to clinical and biological remission receiving a prednisone maintenance dose ≤ 7.5 mg/day. Factors related to the primary endpoint were identified by Cox regression analysis. RESULTS: Overall, 103 patients (MD=53, HD=50) were followed for a median (95%CI) of 2.85 (2.57-3.52) years. Both groups exhibited similar baseline features except for ocular ischaemic manifestations (MD=21%, HD=48%, p=0.004). Patients in the MD group had a shorter time to the primary endpoint (MD=186 [147-223], HD=236 [177-276] days, HR=1.70 [1.12-2.57], p=0.01) with no increase in relapses (MD=39%, HD=50%, p=0.29) or GCA complications (MD=11%, HD=16%, p=0.49). Cumulative prednisone doses at 6 months were 2.47 ± 0.70 g for MD patients and 3.86 ± 1.85 g for HD patients (p<0.001). Adverse effects were more frequent among HD recipients (MD=43%, HD=66%, p=0.02). The only independent factor associated with the primary endpoint was the use of methylprednisolone pulses (HR=2.21 [1.31-3.71], p=0.003). CONCLUSIONS: MD prednisone regimen may be an effective and safe alternative to HD prednisone regimen in GCA. Induction with methylprednisolone pulses predicts a better response, allowing for a less intensive prednisone regimen.

Congenital malformations, chromosomal abnormalities and perinatal results in IVF/ICSI newborns resulting from very poor quality embryos: a case-control study.

AIMS: To explore whether the transfer of very poor quality (VPQ) embryos is associated with an increase in congenital malformations or perinatal problems. METHODS: In this retrospective case-control study, 74 children conceived by in vitro fertilization (IVF) and/or intracytoplasmic sperm injection (ICSI) resulting exclusively from the transfer of VPQ embryos were compared with 1,507 children born after the transfer of top morphological quality (TQ) embryos over the same period of time in the same centers. RESULTS: The prevalence of birth defects in children resulting from VPQ embryos was 1.35% (1/74), similar to the 1.72% (26/1,507) when only TQ embryos were transferred; the rate of chromosomal abnormalities detected was also similar (0.0 vs. 0.4%), as was perinatal mortality. After correcting for multiplicity (higher in the TQ group), the aforementioned parameters remained similar in the two groups. CONCLUSION: Congenital malformations and perinatal complications do not seem to be more common in children born after transfer of VPQ embryos in IVF/ICSI cycles. Given our preliminary data, which need to be confirmed in much larger studies, when only VPQ embryos are available for transfer in IVF/ICSI cycles, we do not believe that they should be discarded with the intention of avoiding birth defects or perinatal complications.

Prognostic value of serum progesterone and LH values on the day of hCG administration in IUI GnRH antagonist cycles.

OBJECTIVE: to evaluate the effect of LH surge and progesterone rise in IUI cycles under gonadotropin stimulation with GnRH antagonist coadministration on pregnancy rates (PR). STUDY DESIGN: The population under study consisted of 152 women prospectively studied and subjected to IUI. RESULTS: The higher the progesterone cutoff value, the lower the PR were 26.5% and 10.9% when the cutoff was 1 ng/mL, 26.0% and 8.6% when the cutoff was 1.2 ng/mL, 25.6% and 7.1% when the cutoff was 1.4 ng/mL and 25.3% and 0% when the cutoff was 1.6 ng/mL. CONCLUSION: In IUI cycles under GnRH antagonist coadministration, serum progesterone levels over 1.0 ng/mL are associated with lower PR, the higher the progesterone levels, the lower the PR.

Four-month incidence of suicidal thoughts and behaviors among healthcare workers after the first wave of the Spain COVID-19 pandemic.

Healthcare workers (HCW) are at high risk for suicide, yet little is known about the onset of suicidal thoughts and behaviors (STB) in this important segment of the population in conjunction with the COVID-19 pandemic. We conducted a multicenter, prospective cohort study of Spanish HCW active during the COVID-9 pandemic. A total of n = 4809 HCW participated at baseline (May-September 2020; i.e., just after the first wave of the pandemic) and at a four-month follow-up assessment (October-December 2020) using web-based surveys. Logistic regression assessed the individual- and population-level associations of separate proximal (pandemic) risk factors with four-month STB incidence (i.e., 30-day STB among HCW negative for 30-day STB at baseline), each time adjusting for distal (pre-pandemic) factors. STB incidence was estimated at 4.2% (SE = 0.5; n = 1 suicide attempt). Adjusted for distal factors, proximal risk factors most strongly associated with STB incidence were various sources of interpersonal stress (scaled 0-4; odds ratio [OR] range = 1.23-1.57) followed by personal health-related stress and stress related to the health of loved ones (scaled 0-4; OR range 1.30-1.32), and the perceived lack of healthcare center preparedness (scaled 0-4; OR = 1.34). Population-attributable risk proportions for these proximal risk factors were in the range 45.3-57.6%. Other significant risk factors were financial stressors (OR range 1.26-1.81), isolation/quarantine due to COVID-19 (OR = 1.53) and having changed to a specific COVID-19 related work location (OR = 1.72). Among other interventions, our findings call for healthcare systems to implement adequate conflict communication and resolution strategies and to improve family-work balance embedded in organizational justice strategies.

Mental impact of Covid-19 among Spanish healthcare workers. A large longitudinal survey.

AIMS: Longitudinal data on the mental health impact of the coronavirus disease 2019 (Covid-19) pandemic in healthcare workers is limited. We estimated prevalence, incidence and persistence of probable mental disorders in a cohort of Spanish healthcare workers (Covid-19 waves 1 and 2) -and identified associated risk factors. METHODS: 8996 healthcare workers evaluated on 5 May-7 September 2020 (baseline) were invited to a second web-based survey (October-December 2020). Major depressive disorder (PHQ-8 ≥ 10), generalised anxiety disorder (GAD-7 ≥ 10), panic attacks, post-traumatic stress disorder (PCL-5 ≥ 7), and alcohol use disorder (CAGE-AID ≥ 2) were assessed. Distal (pre-pandemic) and proximal (pandemic) risk factors were included. We estimated the incidence of probable mental disorders (among those without disorders at baseline) and persistence (among those with disorders at baseline). Logistic regression of individual-level [odds ratios (OR)] and population-level (population attributable risk proportions) associations were estimated, adjusting by all distal risk factors, health care centre and time of baseline interview. RESULTS: 4809 healthcare workers participated at four months follow-up (cooperation rate = 65.7%; mean = 120 days s.d. = 22 days from baseline assessment). Follow-up prevalence of any disorder was 41.5%, (v. 45.4% at baseline, p < 0.001); incidence, 19.7% (s.e. = 1.6) and persistence, 67.7% (s.e. = 2.3). Proximal factors showing significant bivariate-adjusted associations with incidence included: work-related factors [prioritising Covid-19 patients (OR = 1.62)], stress factors [personal health-related stress (OR = 1.61)], interpersonal stress (OR = 1.53) and financial factors [significant income loss (OR = 1.37)]. Risk factors associated with persistence were largely similar. CONCLUSIONS: Our study indicates that the prevalence of probable mental disorders among Spanish healthcare workers during the second wave of the Covid-19 pandemic was similarly high to that after the first wave. This was in good part due to the persistence of mental disorders detected at the baseline, but with a relevant incidence of about 1 in 5 of HCWs without mental disorders during the first wave of the Covid-19 pandemic. Health-related factors, work-related factors and interpersonal stress are important risks of persistence of mental disorders and of incidence of mental disorders. Adequately addressing these factors might have prevented a considerable amount of mental health impact of the pandemic among this vulnerable population. Addressing health-related stress, work-related factors and interpersonal stress might reduce the prevalence of these disorders substantially. Study registration number: NCT04556565.

Thirty-day suicidal thoughts and behaviours in the Spanish adult general population during the first wave of the Spain COVID-19 pandemic.

AIMS: To investigate the prevalence of suicidal thoughts and behaviours (STB; i.e. suicidal ideation, plans or attempts) in the Spanish adult general population during the first wave of the Spain coronavirus disease 2019 (COVID-19) pandemic (March-July, 2020), and to investigate the individual- and population-level impact of relevant distal and proximal STB risk factor domains. METHODS: Cross-sectional study design using data from the baseline assessment of an observational cohort study (MIND/COVID project). A nationally representative sample of 3500 non-institutionalised Spanish adults (51.5% female; mean age = 49.6 [s.d. = 17.0]) was taken using dual-frame random digit dialing, stratified for age, sex and geographical area. Professional interviewers carried out computer-assisted telephone interviews (1-30 June 2020). Thirty-day STB was assessed using modified items from the Columbia Suicide Severity Rating Scale. Distal (i.e. pre-pandemic) risk factors included sociodemographic variables, number of physical health conditions and pre-pandemic lifetime mental disorders; proximal (i.e. pandemic) risk factors included current mental disorders and a range of adverse events-experiences related to the pandemic. Logistic regression was used to investigate individual-level associations (odds ratios [OR]) and population-level associations (population attributable risk proportions [PARP]) between risk factors and 30-day STB. All data were weighted using post-stratification survey weights. RESULTS: Estimated prevalence of 30-day STB was 4.5% (1.8% active suicidal ideation; n = 5 [0.1%] suicide attempts). STB was 9.7% among the 34.3% of respondents with pre-pandemic lifetime mental disorders, and 1.8% among the 65.7% without any pre-pandemic lifetime mental disorder. Factors significantly associated with STB were pre-pandemic lifetime mental disorders (total PARP = 49.1%) and current mental disorders (total PARP = 58.4%), i.e. major depressive disorder (OR = 6.0; PARP = 39.2%), generalised anxiety disorder (OR = 5.6; PARP = 36.3%), post-traumatic stress disorder (OR = 4.6; PARP = 26.6%), panic attacks (OR = 6.7; PARP = 36.6%) and alcohol/substance use disorder (OR = 3.3; PARP = 5.9%). Pandemic-related adverse events-experiences associated with STB were lack of social support, interpersonal stress, stress about personal health and about the health of loved ones (PARPs 32.7-42.6%%), and having loved ones infected with COVID-19 (OR = 1.7; PARP = 18.8%). Up to 74.1% of STB is potentially attributable to the joint effects of mental disorders and adverse events-experiences related to the pandemic. CONCLUSIONS: STB at the end of the first wave of the Spain COVID-19 pandemic was high, and large proportions of STB are potentially attributable to mental disorders and adverse events-experiences related to the pandemic, including health-related stress, lack of social support and interpersonal stress. There is an urgent need to allocate resources to increase access to adequate mental healthcare, even in times of healthcare system overload. STUDY REGISTRATION NUMBER: NCT04556565.

Survival and hepatitis C virus recurrence after liver transplantation in HIV- and hepatitis C virus-coinfected patients: experience in a single center.

INTRODUCTION: Posttransplant hepatitis C virus (HCV) recurrence has been shown to negatively impact graft and patient survivals. It has been suggested that HCV recurrence among HIV- and HCV-coinfected transplant recipients is even more aggressive. OBJECTIVE: To compare the histological severity and survival of posttransplant HCV recurrence between HIV- and HCV-coinfected and HCV-monoinfected patients. PATIENTS AND METHODS: Among 72 adult patients who underwent primary liver transplantation at our institution for HCV-related cirrhosis between October 2001 and April 2007. We excluded one coinfected patient who died on postoperative day 5 leaving 12 HIV- and HCV-coinfected patients for comparison with 59 monoinfected patients. When listed, all coinfected patients fulfilled the criteria of the Spanish Consensus Document for transplantation in HIV patients. Immunosuppression did not differ between the two groups: all were treated with tacrolimus + steroids (slow tapering). Aggressive HCV recurrence was defined as cholestatic hepatitis and/or a fibrosis grade > or =2 during the first posttransplant year. RESULTS: Coinfected patients were younger than monoinfected patients: 45 +/- 6 years vs 55 +/- 9 years (P = .0008). There were no differences in Child score, Model for End-stage Liver Disease score, donor age, graft steatosis, ischemia time, HCV pretransplant viral load or genotype between the groups. Significant rejection episodes were also equally distributed (25% vs 14%; P = .38). Seven coinfected patients and 29 monoinfected patients developed aggressive HCV recurrences (58% vs 49%; P = .75). Median follow-up was 924 days. Global survival at 3 years was 80%. Survivals at 1, 2, and 3 years were 83%, 75%, 62% in the coinfected vs 98%, 89%, 84% in the monoinfected patients, respectively (log-rank test = 0.09). CONCLUSIONS: The severity of histological recurrence was similar among HIV- and HCV-coinfected and monoinfected HCV liver recipients in the first posttransplant year. Mortality attributed to recurrent HCV was similar in the groups. There were no short-term (3-year) differences in survival between the two groups of patients.

Hepaticojejunostomy in Orthotopic Liver Transplant: A Retrospective Case Control Study.

The reported biliary morbidity rate for deceased donor full-size orthotopic liver transplantation is up to 30%. The technique used may be influenced by multiple factors, and in some situations, biliary reconstruction must be carried out through Roux-en-Y hepaticojejunostomy. The aim of our study was to determine the results of the orthotopic liver transplantation according to the technique used in the biliary reconstruction. A retrospective study was performed with the first 1000 orthotopic liver transplants (951 patients) carried out consecutively (1996-2013) with follow-up until 2017. A matched case-control study was designed in 1:3 ratio (47/136) to compare the reconstruction by hepaticojejunostomy vs the end-to-end coledoco-coledocostomy. Hepaticojejunostomy was associated with patients with cholestatic (44.7% vs 3.7%) and ischemic disease (14.9% vs 0%; P < .001) and previous transplant (29.8% vs 1.5%; P = .003). The mean biliary duct reconstruction, surgery, and cold ischemia times were also higher. Vascular complications were significantly more frequent in the hepaticojejunostomy group (36.1% vs 10.4%; P < .001), mainly because of differences in early arterial complications. Nevertheless, there were no differences in the total biliary complication (21.2% vs 16.9%; P = .5). The biliary leakage rate and the biliary stricture rate were also similar. Hepaticojejunostomy in orthotopic liver transplantation presented longer biliary reconstruction, surgery, and cold ischemia times when compared with end-to-end coledoco-coledocostomy. In addition, it was followed by a higher incidence of arterial complications but had similar biliary complication rate and graft survival. Differences could be explained by the fact that hepaticojejunostomy was used more often in cholestatic or ischemic diseases and in retransplant procedures.

Prognostic value of maximum standardized uptake value measured by pretreatment 18F-FDG PET/CT in locally advanced head and neck squamous cell carcinoma.

PURPOSE/OBJECTIVES: To evaluate the prognostic impact of maximum standardized uptake value (SUVmax) in patients with locally advanced head and neck squamous cell carcinoma (HNSCC) undergoing pretreatment [F-18] fluoro-D-glucose-positron emission tomography/computed tomography (FDG PET/CT) imaging. MATERIALS/METHODS: Fifty-eight patients undergoing FDG PET/CT before radical treatment with definitive radiotherapy (±concomitant chemotherapy) or surgery + postoperative (chemo)radiation were analyzed. The effects of clinicopathological factors (age, gender, tumor location, stage, Karnofsky Performance Status (KPS), and treatment strategy) including primary tumor SUVmax and nodal SUVmax on overall survival (OS), disease-free survival (DFS), locoregional control (LRC), and distant metastasis-free survival (DMFS) were evaluated. Kaplan-Meier survival curves were generated and compared with the log-rank test. RESULTS: Median follow-up for the whole population was 31 months (range 2.3-53.5). Two-year OS, LRC, DFS and DMFS, for the entire cohort were 62.1, 78.3, 55.2 and 67.2%, respectively. Median pretreatment SUVmax for the primary tumor and lymph nodes was 11.85 and 5.4, respectively. According to univariate analysis, patients with KPS < 80% (p < 0.001), AJCC stage IVa or IVb vs III (p = 0.037) and patients undergoing radiotherapy vs surgery (p = 0.042) were significantly associated with worse OS. Patients with KPS < 80% (p = 0.003) or age ≥65 years (p = 0.007) had worse LRC. The KPS < 80% was the only factor associated with decreased DFS (p = 0.001). SUVmax of the primary tumor or the lymph nodes were not associated with OS, DFS or LRC. The KPS < 80% (p = 0.002), tumor location (p = 0.047) and AJCC stage (p = 0.025) were associated with worse cancer-specific survival (CSS). According to Cox regression analysis, on multivariate analysis KPS < 80% was the only independent parameter determining worse OS, DFS, CSS. Regarding LRC only patients with IK < 80% (p = 0.01) and ≥65 years (p = 0.01) remained statistically significant. Nodal SUVmax was the only factor associated with decreased DMFS. Patients with a nodal SUVmax > 5.4 presented an increased risk for distant metastases (HR, 3.3; 95% CI 1.17-9.25; p = 0.023). CONCLUSIONS: The pretreatment nodal SUVmax in patients with locally advanced HNSCC is prognostic for DMFS. However, according to our results primary tumor SUVmax and nodal SUVmax were not significantly related to OS, DFS or LRC. Patients presenting KPS < 80% had worse OS, DFS, CSS and LRC.

Donors older than 70 years in liver transplantation.

INTRODUCTION: Expansion of donor criteria has become necessary with the increasing number of liver transplantation candidates, as aged donors who have been considered to yield marginal organs. METHODS: Our database of 477 liver transplants (OLT) included 55 cases performed from donors at least 70 years old vs 422 with younger donors. We analyzed pretransplantation donor and recipient characteristics as well as evolution of the recipients. RESULTS: The old donor group showed significantly lower ALT (23 +/- 17 vs 48.9 +/- 67; P = .0001) and LDH (444 +/- 285 vs 570 +/- 329; P = .01). There was a trend toward fewer hypotensive events in the aged donor group (27.2% vs 40.5%; P = .07). No steatosis (>10%) was accepted in the old donor group. Cold ischemia time was statistically shorter for the aged donors (297 +/- 90 minutes vs 346 +/- 139 minutes; P = .03). With these selected donors, the results were not different for primary nonfunction, arterial and biliary complications, hospitalization, acute reoperation or acute retransplantation, and hospital mortality when donors > or =70 years old were compared to younger donors. Functional cholestasis, neither related to rejection nor to biliary complications, was seen more frequently in old donor recipients (40% vs 22%; P = .03). No differences in 1, and 3 year survivals were observed between recipients of donors over 70 years old and these of younger organs: 93.8% and 90.6% vs 90.7% and 82.8%, respectively. CONCLUSION: When using selected donors > or =70 years old the outcomes were comparable to those obtained with younger donors. Strict selection is necessary to achieve good long-term survival.

Thrombin generation and fibrinolysis in the thrombotic thrombocytopenic purpura and the hemolytic-uremic syndrome.

Prothrombin fragment 1 + 2 (F1 + 2) and thrombin-antithrombin complexes (TAT), as well as other coagulation and fibrinolysis parameters, were studied in a series of 13 patients affected by thrombotic thrombocytopenic purpura (TTP) or hemolytic-uremic syndrome (HUS). Fragment F1 + 2 was found to be increased in all patients at diagnosis (patients' range, 1.21-19.03 nmol/l; normal limits, 0.28-1.08 nmol/l), and remained also higher than normal after treatment with plasma exchange (patients' range, 1.5-4.01 nmol/l). Even though the analysis of fibrinolysis markers did not show a definite state of hypo or hyperfibrinolysis in the systemic circulation, enhanced circulating D-dimer levels (0.53-12.6 micrograms/ml, normal levels of 0.03-0.29 micrograms/ml) indicated that a certain grade of fibrin lysis was present at previously formed thrombi. Plasma PAI-1 activities either on admission (9.2-38.2 U/ml) and after plasma exchange therapy (2.6-38.6 U/ml) showed a behavior irrespective of t-PA:Ag changes, and post-plasmapheresis values remained high only in patients with fatal neurological outcome. Nevertheless, no correlations between clinical and laboratory data could be established useful for the TTP/HUS prognosis. We conclude that increased thrombin generation occurring in damaged areas is appropriately inhibited by antithrombin III in the systemic circulation, avoiding consumption coagulopathy to develop in uncomplicated patients. In addition, fibrinolysis data suggest that elevated PAI-1 may decisively favor the development of microvascular thrombi.

Influence of three factors on the diagnostic effectiveness of transthoracic needle aspiration in pneumonia.

Prior antibiotic therapy, size of the infiltrate, and the person who performed the technique were the three factors that we studied to assess their influence on the effectiveness of transthoracic needle aspiration (TNA). Ninety-one patients with a diagnosis of severe bacterial pneumonia, who underwent TNA, have been included in the study. The technique was carried out with an ultrathin needle gauge 25 and without fluoroscopic control. A univariate (UA) and a multivariate statistical analysis were made. The sensitivity of TNA was 34.1%. Fifty-seven of 91 (62.6%) had received antibiotic therapy prior to TNA; sensitivity was higher in nontreated patients than in treated patients (p = 0.0033; UA). There were 34 patients with an infiltrate that was smaller than a lobe (MINLOB); 39 cases affected a complete lobe (LOB) and 18 more than one lobe (MAJLOB). The TNA sensitivity was higher in LOB cases than in MINLOB cases (p = 0.0004; UA) while when comparing LOB cases and MAJLOB cases, sensitivity was higher in the former (p = NS; UA). In 28 of 91 cases (30.8%), the TNA was performed by A (a trained physician who regularly carries out the technique) and in 63 of 91 cases (69.2%) by B (other physicians, 10 in our study, who sporadically perform the technique). The TNA sensitivity was higher when the technique was performed by A, although this difference was not significant; if we add negative TNA with leukocytes present in Gram stains (which would indicate that aspiration was done in the correct area) to positive TNA, the difference between A and B was higher (p = 0.0248). The multivariate statistical analysis confirmed that there are two variables that are independently connected to a positive TNA (prior antibiotic therapy and size of the infiltrate). As regards the variable "person who carries out the technique," a significant association with a positive TNA was not established, although the estimations we obtained show a possible clinical relevance.

Epidemiology of endometriosis in infertile women.

OBJECTIVE: To assess the epidemiological factors linked to endometriosis in infertile women. SETTING: Academic tertiary hospital. DESIGN: Case-control study. PATIENTS: One hundred seventy-four infertile women with endometriosis and 174 infertile women without endometriosis, all of them studied by laparoscopy. RESULTS: Women with endometriosis and infertility had a higher frequency of cycles < or = 27 days (26.4% versus 16.7%). A trend to a protective effect of smoking was detected. Social class, reproductive history, infertility history, previous abortions, age, family history, age at menarche, and duration of menstrual flow were similar in both groups. CONCLUSION: Cycles < or = 27 days was the only risk factor that seemed to be associated to endometriosis in infertile patients. However, predictive values were low. A trend to a protective effect of smoking was detected.

Intrauterine insemination with frozen sperm increases pregnancy rates in donor insemination cycles under gonadotropin stimulation.

OBJECTIVE: To compare the efficacy of IUI donor and pericervical insemination donor in frozen sperm insemination cycles under gonadotropin stimulation. DESIGN: Couples where infertility was caused by male conditions were randomized into two groups: IUI and pericervical insemination. Semen samples, gonadotropin stimulation, and ovarian monitoring were the same in both groups. One IUI was performed per cycle as against two pericervical inseminations. SETTING: The donor insemination program at the Human Reproduction Unit at the Hospital of Cruces, Pais Vasco University. PATIENTS: Eighty-eight women (47 IUI and 41 pericervical insemination) with at least one patent fallopian tube and < 40 years of age. MAIN OUTCOME MEASURE: Intrauterine gestational sac observed by transvaginal ultrasound. RESULTS: Per woman pregnancy rate (PR) was higher in IUI than in pericervical insemination (65.96% versus 41.46%, odds ratio [OR] = 2.73, confidence interval [CI] = 1.06 to 7.2). Pregnancy rates were always higher in IUI irrespective of woman and husband's status, but statistical significance was not reached in any subgroups analyzed independently. Per cycle PR was also significantly higher in IUI than in pericervical insemination: 24.03% (31/129) versus 11.89% (17/143) (OR = 2.34, CI = 1.17 to 4.71). Moreover, cumulative PR was higher in IUI (86% versus 49.5%) (OR = 6, CI = 1.98 to 18.80). CONCLUSION: Per woman and per cycle PRs were significantly higher in IUI.

Women who are not exposed to spermatozoa and infertile women have similar rates of stage I endometriosis.

OBJECTIVE: To compare the prevalence of endometriosis and its different stages in infertile women and women not exposed to spermatozoa. DESIGN: Prospective study. SETTING: Artificial insemination donor program at a university hospital. PATIENT(S): One hundred fifty women unable to conceive because they had not been exposed to spermatozoa (134 with azoospermic partner, 10 with an HIV-positive partner, and 6 without a male partner). Controls were 750 women in infertile couples in which the male partner had normal sperm. INTERVENTION(S): Laparoscopy was systematically performed in a blinded manner in both groups as part of the infertility work-up. MAIN OUTCOME MEASURE(S): Diagnosis of endometriosis. RESULT(S): In unexposed women and controls, the prevalence of endometriosis was similar (32% and 34.5%). Rates of stage I disease were also similar in both groups (26% and 19.3%). There was a significant trend toward higher stages of endometriosis in infertile women (stage II disease, 3.3% vs. 5.7%; stage III disease, 1.3% vs. 3.1%; stage IV disease, 1.3% vs. 6.4%). Endometriosis was not associated with the few demographic characteristics that differed between groups. CONCLUSION(S): From an epidemiologic point of view, stage I endometriosis is not more common in infertile women than in unselected women. However, stage II to IV endometriosis was more frequent in infertile women. Whereas a relation between stage I endometriosis and infertility seems unlikely, the relation between stages II to IV endometriosis and infertility seems possible.

Prevention of thromboembolism with ticlopidine shortly after valve repair or replacement with a bioprosthesis.

BACKGROUND AND AIMS OF THE STUDY: This study investigated the efficacy of postoperative ticlopidine as antiplatelet therapy in patients shortly after heart valve repair or replacement. METHODS: Between 1990 and 1995, 235 consecutive patients underwent either valve repair (n = 67) or replacement with a bioprosthesis (n = 168). The bioprostheses used were Carpentier-Edwards porcine or pericardial (n = 158) valves, Prima stentless valves (n = 3) and cryopreserved homografts (n = 7). Types of repair were aortic (one), mitral annuloplasty with Carpentier ring (65) and tricuspid repair (one). Mean patient age was 67 (range: 16 to 83) years for valve replacement and 57 (range: 32 to 74) years for repair (p < 0.01). Atrial fibrillation occurred in 34% of patients. The hospital mortality rate was 11% (26 patients). Of the 209 survivors, 137 were assigned to antiplatelet treatment with ticlopidine for the first three months of follow up. The other 72 received either oral anticoagulation (coumadin; n = 40), aspirin (n = 14) or no medication (n = 18). In 15 patients, ticlopidine treatment was interrupted due to diarrhea (13 cases), mild allergic reaction (one) or anemia (one). The mean follow up was 3.2 years (range: 1 month to 6 years); cumulative follow up was 684 patient-years (pt-yr) and was complete in 96% of cases. RESULTS: There were two episodes of thromboembolism in the ticlopidine group at 1 month and 6 months respectively, with a linearized incidence of 0.5% pt-yr. In the coumadin group there were four episodes of thromboembolism, three within the first three months of follow up. The linearized incidence was 3% pt-yr (p < 0.01). There were three episodes of hemorrhage in the ticlopidine group in the first three months of follow up and one in the coumadin group. The linearized incidence was 0.75% pt-yr. CONCLUSIONS: Following heart valve repair or replacement with a bioprosthesis, the first three months is a high-risk period for thromboembolism. Ticlopidine seems to prevent this complication better than conventional therapy with oral anticoagulants. Nevertheless, hemorrhage continues to be a problem with ticlopidine therapy.

Efficacy of radiosynovectomy of the knee in rheumatoid arthritis: evaluation with magnetic resonance imaging.

The intra-articular injection of a radiopharmaceutical agent (radiosynovectomy) produces a reduction of the synovial inflammatory process. The inflammed synovial membrane can be identified with magnetic resonance imaging after the intravenous administration of gadolinium (MRI-Gd). A 6-month prospective study was carried out in 10 patients with rheumatoid arthritis after radiosynovectomy of the knee. The efficacy was evaluated with clinical parameters and MRI-Gd. A progressive amelioration of synovial effusion, pain, articular range of mobility, total leucocytes count in synovial fluid and synovial membrane thickness through MRI-Gd was observed. The global efficacy was considered to be good in six patients, fair in three and bad in one. The study shows for the first time that MRI-Gd allows the evaluation of the response of the synovial membrane to radiosynovectomy.

Fetal cardiotocography and acid-base status during cesarean section.

OBJECTIVE: To assess the fetal well-being during cesarean section, in relation to the previous fetal condition. DESIGN: Observational study. SETTING: University Hospital. PATIENTS PARTICIPANTS: 204 women undergoing cesarean section (203 intrapartum cesarean sections): 177 with general anesthesia and 27 with spinal anesthesia. MATERIAL AND METHODS: We compared the fetal heart records of the last 30 min before cesarean section (during the first stage of labor) with those during cesarean section. Scalp blood analysis 30 min before the beginning of anesthesia induction was compared with umbilical artery analysis at delivery. MAIN OUTCOME MEASURES: Cardiotocography. Acid-base analysis. Apgar scores. RESULTS: During cesarean section there was a reduction in uterine activity, an increase in silent tracings and a decrease in late decelerations. Umbilical artery pH was lower than scalp pH (7.23+/-0.06 vs 7.30+/-0.06). Oxygen saturation was also lower (14.43+/-8.58% vs 18.99+/-8.4%). The values of pCO2 and of base deficit were higher. During cesarean section low values of modified Fischer scores were associated with low pH values of umbilical artery and low Apgar scores. CONCLUSION: Silent tracings appearing during cesarean section usually do not indicate fetal distress. Poor intracesarean fetal heart tracings were associated with worse indicators of neonatal well-being. Although umbilical pH were lower than scalp values, when the correction described in the literature was applied, the difference was of little clinical relevance. It is concluded that anesthesic, pharmacological and surgical events have slight repercussion in fetal well being. However, in a few cases fetal heart monitoring during cesarean section could detect otherwise undiagnosed cases of transient acidemia or depression in the fetus.

Endometriosis and spontaneous abortion rate: a cohort study in infertile women.

OBJECTIVE: To ascertain if there is an association between endometriosis and spontaneous abortion. DESIGN: Prospective cohort study. SETTING: Medical School Hospital. POPULATION: 174 infertile women laparoscopically diagnosed with endometriosis and 174 infertile women in which endometriosis was ruled out by laparoscopy, in the same period of time. MAIN OUTCOME MEASURE: Spontaneous abortion. Non-progressive gestational sac and/or histological study. RESULTS: Per woman abortion rate was 7.47% (13/174) in the endometriosis group, similar to 5.74% (10/174) in the infertile women without endometriosis (RR=1.32: CI=0.53-3.36). Nor were there any differences in the per pregnancy abortion rate: 20.96% (13/62) in endometriosis vs. 16.94% (10/59) in non-endometriosis (RR=1.3; CI=0.47-3.57). The abortion rate was similar in the different AFS stages: 22.86% (8/35) in stage I, 16.67% (3/18) in II, 25% (1/4) in III and 20% (1/5) in IV. In stage I no differences were observed in patients who were managed expectantly or with medical treatment. CONCLUSION: Endometriosis is not associated with an increased abortion rate. The severity of disease expressed by AFS staging is not associated with an increase in the abortion rate. In stage I the treatment of endometriosis did not decrease abortion rates.

Spontaneous pregnancy in couples waiting for artificial insemination donor because of severe male infertility.

OBJECTIVE: To assess the spontaneous fertility in couples with severe seminal conditions while waiting for artificial insemination donor. STUDY DESIGN: Prospective follow-up during a period of 24 months. SETTING: University Medical School. PARTICIPANTS: There were 285 couples in which the male had a very severe seminal pathology: 166 azoospermia, 86 oligozoospermia and 33 severe asthenozoospermia. OUTCOME MEASURES: Pregnancy rates after being included on waiting list. RESULTS: The spontaneous pregnancy rate was 3.2% (9/285), per month spontaneous pregnancy rate being 0.13%. Spontaneous pregnancy rate was 0% in azoospermia (0/166). versus 7.6% (9/119) in non-azoospermia cases. Spontaneous pregnancy rate was 8.5% (4/47) in the group with less than 0.1 million motile sperm/cc, 6.5% (3/46) in the group between 0.1 and 1 million/cc and 7.7% (2/26) in the group with 1-2 million/cc. CONCLUSION: In a 2-year follow-up, pregnancy rate among non-azoospermic couples before undergoing artificial insemination was 7.6%. Extramatrimonial pregnancy (based on anamnesis and sperm analysis) seemed to be uncommon. Even in cases with less than 0.1 million of motile sperm/cc there was not a negligible spontaneous pregnancy rate.