Impact of bodyweight/body mass index on the effectiveness of emergency contraception with levonorgestrel: a pooled-analysis of three randomized controlled trials.

OBJECTIVE: A pooled analysis of two randomized controlled trials (RCTs) suggested that increased bodyweight and body mass index (BMI) may be associated with a greater probability of pregnancy. To address this issue we investigated whether higher bodyweight and/or BMI negatively impacted the risk of pregnancy in women receiving LNG-EC (levonorgestrel - emergency contraception) after unprotected sexual intercourse in a pooled analysis of three large multinational RCTs conducted by the World Health Organization (WHO). METHODS: A pooled analysis of three double-blind, multinational RCTs conducted by the WHO to investigate the efficacy of LNG-EC in the general population. All analyses were done on the per-protocol set (PPS) which included 5812 women who received LNG-EC within 72 hours following unprotected sexual intercourse. The analysis was based on logistic regression, with pregnancy as the outcome. BMI and weight were represented in the same model. RESULTS: A total of 56 pregnancies were available for analysis in the PPS. Increasing bodyweight and BMI were not correlated with an increased risk of pregnancy in the studied population. A limitation of this study is that despite the large study population in the pooled analysis there were relatively small numbers of women in the high-BMI and high-bodyweight subgroups. CONCLUSION: LNG-EC is effective for preventing pregnancy after unprotected intercourse or contraceptive failure and no evidence was found to support the hypothesis of a loss of EC efficacy in subjects with high BMI or bodyweight. Therefore, access to LNG-EC should not be limited only to women of lower bodyweight or BMI.

Findings of a hospital surveillance-based outcome evaluation study for Clostridium difficile-associated colitis.

We completed a prospective study of 164 patients involved in a Clostridium difficile surveillance programme, evaluating a range of variables such as disease severity, treatment regimen and known clinical risk factors, for their effect on case lethality. The aim of this study was to determine if there are any additional clinical variables worth considering for inclusion in the therapeutic decision-making process. Beyond common risk factors, secondary immunodeficiencies such as diabetes mellitus, malignancy, autoimmune disease, immunosuppressive therapy and chronic hepatitis were assessed. Overall case lethality was 23%. There was a suggestion that regular proton pump inhibitor use in past medical history might be associated with greater lethality. Immunosuppressive therapy within 1 month before the onset of diarrhoea was associated with a significant four-fold lethality increase. This last finding may have the potential to further improve therapeutic judgement if used as an explicit component of a revised scoring system. In relation to Clostridium difficile-associated colitis, immunosuppressive therapy as a red flag entity, as described here, has not been previously published.

Distinct phenotypes in mixed connective tissue disease: subgroups and survival.

The aim of the present study was to assess the autoantibody profile, dominant clinical symptoms and cluster characteristics of different mixed connective tissue disease (MCTD phenotypes. Two-hundred-and-one patients with MCTD were followed-up longitudinally. Five clinical parameters, Raynaud's phenomenon, pulmonary artery hypertension (PAH), myositis, interstitial lung disease (ILD), erosive arthritis and five auto-antibodies besides anti-U1RNP, antiendothelial cell antibodies (AECA), anti-CCP, anti-cardiolipin (anti-CL), anti-SSA/SSB and IgM rheumatoid factor (RF) were selected for cluster analysis. The mean age of patients was 52.9 ± 12.4 years and the mean follow-up of the disease was 12.5 ± 7.2 years. Patients were classified into three cluster groups. Cluster 1 with 77 patients, cluster 2 with 79 patients and cluster 3 with 45 patients. In cluster 1 the prevalence of PAH (55.8%; p < 0.001), Raynaud's phenomenon (92.2%; p < 0.001) and livedo reticularis (24.6%, p < 0.001) was significantly greater than in cluster 2 and 3. In cluster 2, the incidence of ILD (98.7%; p < 0.001), myositis (77.2%; p < 0.001), and esophageal dysmotility (89.8%; p < 0.001) was significantly greater than that in cluster 1 and 3. In cluster 3, anti-CCP antibodies were present in 31 of 45 patients (68.8%) with erosions. Anti-CCP antibodies were present in 37 of 42 patients (88.0%) with erosions. PAH, angina, venous thrombosis was observed in cluster 1 and pulmonary fibrosis in cluster 2, musculosceletal damage, gastrointestinal symptoms and osteoporotic fractures were most frequent in cluster 3. Cumulative survival assessment indicated cluster 1 patients having the worst prognosis. Cluster analysis is valuable to differentiate among various subsets of MCTD and useful prognostic factor regarding the disease course.

[The reconstruction of conjunctival socket after enucleation of the eye in post--two possibilities of surgical solution]. / Rekonstrukcia spojovkového vaku po enukleácii ocného bulbu v minulosti--dva spôsoby chirurgického riesenia.

UNLABELLED: The aim of article was to describe two possibilities of reconstruction of contracted and deformed conjunctival socket at the patient undergoing enucleation of the eye many years ago. METHOD: The free full-thickness mucosa graft was used in local anaesthetic for reconstruction conjunctival socket at the first patient. The amnion membrane was used in the second case with correction of ectropion of lower eyelid. RESULTS: The good cosmetic and stabile effect was obtained in both cases.

Phacoemulsification of mature and hard nuclear cataracts.

UNLABELLED: The aim of the study was to compare the best corrected visual acuity (BCVA) before and at the 1st day after the cataract surgery for mature or the hard nuclear cataract. The phacoprobe NeoSoniX equipment Legacy (Alcon Laboratories) was used for the cataract surgery. Trypan blue for vital staining of the anterior capsule was used in case of the white cataract. The prevalence and the effect of the complication on BCVA were evaluated. 561 eyes were operated for the cataract. 57 (10.16%) had cataract grade NO4-NC6 and NC4-NC6 (LOCS III). Postoperative complications were: the transient edema of cornea in 8 eyes (14%), one case of (1.75%) erosio cornea caused by patient and in one case (1.75%) the intraocular pressure was elevated for a short time. CONCLUSION: The results of this study confirm that phacoemulsification is an appropriate method for the resolution of cataracts at advanced stages (Tab. 2, Fig. 3, Ref. 24). Full Text (Free, PDF) www.bmj.sk.

Alterations of carbohydrate and lipoprotein metabolism in childhood obesity--impact of insulin resistance and acanthosis nigricans.

AIM: To study the prevalence of alterations of glucose and lipoprotein metabolism and the impact of acanthosis nigricans (AN) in childhood obesity. PATIENTS AND METHODS: 113 obese children, 57 with simple obesity (SO) and 58 with obesity and AN (OAN). Oral glucose tolerance test was performed, serum glucose, insulin and lipoprotein parameters were determined, and insulin resistance/sensitivity indices were calculated. RESULTS: Insulin resistance, basal and reactive hyperinsulinemia, impaired glucose tolerance (IGT) and dyslipidemia were found to be frequent conditions in children with OS as well as OAN. Reactive insulinemia was more pronounced in OAN than in SO, and insulin resistance was more frequent when AN was more prominent. Triglycerides were higher and HDL-C was lower, and atherogenic dyslipidemia was more frequent in OAN compared to SO. CONCLUSION: Children with obesity form a risk population. AN is a factor which can be used in metabolic risk factor clustering estimation in childhood obesity.

Factors influencing hemorrhagic transformation in ischemic stroke: a clinicopathological comparison.

As hemorrhagic transformation (HTr) is a frequent complication and can worsen the outcome of acute ischemic stroke, our aim was to assess the risk factors of HTr. Using the database of our neuropathological laboratory, 245 consecutive acute ischemic stroke patients were analyzed. An exploratory logistic regression procedure was carried out to find the best multiple model identifying the factors associated with HTr. The autopsy revealed ischemic infarct in 175 (71%) and ischemic infarct with HTr in 70 (29%) patients. Mean age was 71.5 +/- 11.4 years (mean +/- SD) and 74.8 +/- 10.2 years (mean +/- SD), respectively. The multiple model confirmed age in case of embolic stroke, and diabetes mellitus and infarct size as independent risk factors of HTr. It seems that not serum glucose level but diabetes mellitus in the case history is an independent predictor of HTr.

Pelvic inflammatory disease is a risk factor for cervical cancer.

The acquisition of human papillomavirus (HPV), the most important etiological agent of cervical cancer, does not cause clinical complaints. Although HPV spreads together with agents causing pelvic inflammatory disease (PID) with complaints forcing the patient to seek medical advice, PID has not yet been evaluated as a predictor of cervical cancer. The present study aimed to determine the relationship between PID and HPV in order to evaluate the possible risk factor role of PID for cervical cancer. Two groups of patients were studied: (i) 2,215 women with PID; (ii) 4,217 women participating in a cervical cancer screening programme who were found to have cytological atypia, mucopurulent cervicitis or other colposcopically detected disorders but were free of symptoms of PID. The presence of HPV and other STD agents in cervical smears was detected with polymerase-chain reaction. HPV prevalence was 33.74% in patients with PID and 26.40% in the group of women without PID (p < 0.001). This suggests that patients suffering from PID apparently have a higher risk of cervical cancer.

Three-dimensional time-of-flight MR angiography in trigeminal neuralgia on a 0.5-T system.

The goal of this study was to analyze the diagnostic value of three-dimensional time-of-flight magnetic resonance angiography (3D TOF MRA), performed on a 0.5-T system in the detection of neurovascular compression in patients with trigeminal neuralgia (TN). One hundred seventy-two TN patients were examined using plain and contrast-enhanced 3D TOF MRA on a 0.5-T system. Maximum intensity projection (MIP) reconstruction was performed in three standard planes. Both the original and the reconstructed images were studied to search for vascular compression shown by close neurovascular contact and/or dislocation of the trigeminal nerve. Forty-two TN patients underwent surgical exploration of the posterior fossa. Results of MRA were compared with clinical data in all cases and to result of surgery in the surgically treated cases. Neurovascular contact at the root entry zone of the trigeminal nerve was detected on the symptomatic side in 94 patients, and on the asymptomatic side in 12 patients. Sensitivity, specificity, accuracy, as well as positive and negative predictive value of 3D TOF MRA in the detection of neurovascular compression in the patient group undergoing surgery, were 97.6, 92.5, 95.0, 93.0, and 97.4%, respectively. Three-dimensional TOF MRA performed on a 0.5-T system appears to be not less effective than similar examinations by higher field strength devices in the detection of neurovascular contact. This sequence accurately demonstrates the presence of neurovascular compression, and in this way valuable information may be achieved for the planning of surgical therapy of patients with trigeminal neuralgia.

Clinical value of technetium-99m-HMPAO-labeled leukocyte scintigraphy and spiral computed tomography in active Crohn's disease.

OBJECTIVES: The diagnostic accuracy of technetium-99m-HMPAO-labeled leukocyte scintigraphy (LS) and spiral CT for the detection of inflammatory activity was assessed; the extent of the inflammation and the complications were compared with the clinical and laboratory parameters and with the endoscopic and radiological findings in patients with clinically active Crohn's disease (CD). METHODS: Twenty-eight patients (13 men, 15 women, average age 32.5 yr, range: 18-59 yr) with an acute exacerbation of CD were enrolled in the study. The disease behavior type and the maximum extent of inflammation were established by means of endoscopy (jejunoscopy and colonoscopy) and enteroclysis. Nine patients with severe complications (abscess and stenosis) underwent operation. The GI tract was divided into five segments (small bowel, ascending colon, transverse colon, descending colon, and rectosigmoid), the LS, CT, endoscopic, and radiological pictures of all segments were graded (range: 0-3) and the scores were summed and compared. RESULTS: The investigations indicated that LS and CT had sensitivities of 76.1% and 71.8%, specificities of 91.0% and 83.5%, and accuracies of 82.6% and 77.5%, respectively, for detection of segmental inflammatory activity. With regard to the disease behavior type, the sensitivities of LS and CT were, respectively, 77% and 100% in the penetrating-fistulizing, 80% and 73% in the stricturing, and 68% and 64% in the inflammatory form of CD. CT detected all abdominal abscesses, whereas the diagnostic value of LS for the detection of the complications of CD was lower. The inflammatory activity scores measured by LS displayed a closer correlation than that of CT with the Best index (r = 0.71, p < 0.0005 vs r = 0.63, p < 0.001), the van Hees index (r = 0.61, p < 0.005 vs r = 0.59, p < 0.005), the serum fibrinogen level (r = 0.67, p < 0.005 vs r = 0.59, p < 0.005), or the C-reactive protein level (r = 0.64, p < 0.005 vs r = 0.51, p < 0.01). CONCLUSIONS: Both LS and CT are valuable noninvasive diagnostic methods in cases involving severe, active CD. LS seemed better for the detection of segmental inflammatory activity, whereas CT displayed excellent suitability for the recognition of complications: abdominal abscesses were diagnosed with 100% efficiency.

[Treatment of renal artery stenoses with stent implantation]. / Arteria renalis-szúkületek kezelése stentimplantatióval.

The authors report on their experience with the treatment of renovascular hypertension by stent implantation. In the past 4 years different types of stents (Palmaz [9], Palmaz-Corinthian [4], Memotherm [1] and AVE [1]) were implanted into 15 renal arteries of 11 patients. The indication was primary in 8 cases, and secondary in 3 patients, because of restenosis of a previously dilated renal artery. 14 stents were implanted into narrowed renal arteries, and in the remaining one case a stent was placed in an occluded renal artery immediately after recanalization. The technical success was 100%. In all but the recanalized case in which the renal artery was occluded, stents are still open. On the basis of this experience and the literature, the authors suggest the more extensive usage of this less invasive method.

[Value of CT-guided biopsy compared to fluoroscopy-guided transthoracic biopsy and bronchoscopic sampling in the diagnosis of pulmonary nodules]. / CT-vezérelt szövethenger biopszia jelentösége gócos tüdöelváltozások diagnosztikájában--átvilágítás ellenörzésével végzett transthoracalis biopsziával és bronchoscopos mintavétellel összehasonlítva.

CT-guided histological sampling is nowadays used routinely in the differential diagnosis of focal lung diseases with no characteristic morphology. The aim of this study was to determine the value of the method. CT-guided core biopsy was performed in 25 patients with pulmonary nodules. 16 patients underwent bronchoscopy where cytological sampling was also carried out, while 5 patients underwent fluoroscopically guided biopsy. The histological diagnosis resulting from CT-guided biopsy specimens was compared with the findings from the other diagnostic procedures (bronchoscopy or fluoroscopically guided biopsy), with the results of surgery and/or chemotherapy and with the follow-up data. The result of CT-guided biopsy was true in 20/25 and falls in 5/25 cases. Of the 16/25 patients undergoing bronchoscopy, 13/16 gave negative results. In 11/16 cases, the result of the CT-guided biopsy was positive. The fluoroscopically guided biopsy was negative in 4/5 cases, and in 3/5 of these cases the diagnostic CT-guided biopsies proved positive. Our results demonstrate the better diagnostic value of CT-guided core biopsy relative to fluoroscopically guided biopsy or bronchoscopic sampling in those cases where the size and localization of the nodule make it inaccessible with the latter two methods.

[Management of severe orthostatic hypotension by head-up-tilt posture and administration of fludrocortisone]. / Súlyos fokú orthostaticus hypotonia kezelése "head-up-tilt" fektetéssel és fludrocortisonnal.

A case of a 66-year-old man with recurrent episodes of syncope is reported. The syncopal attacks started five years ago in sitting and standing positions. At the time of admission the fainting attacks occurred 2-3 times per day. The diagnostic tests revealed severe orthostatic hypotension. The medical treatment was started with salt enriched diet and fludrocortisone. The efficacy of the therapy was tested by using the tilt table test with a self developed computer system consisting of a non-invasive finger blood pressure monitor and ECG. The orthostatic tolerance improved with the medical therapy, however remained unsatisfactory for the patient's daily activity. Though the patient had less frequent symptoms, he had still sustained episodes of recurrent syncopes. The medical therapy was than combined with sleeping in the 15 degrees head-up-tilt position. The repeat tilt table test was performed two weeks after initiation of the 15 degrees head-up-tilt sleeping. The orthostatic tolerance was markedly improved. The patient became free of symptoms and during a four-week follow-up his condition remained stable. At the control the patient reported about deterioration of his symptoms as a result of the discontinuation of sleeping in "head-up-tilt" position for two weeks. The objective signs leading to aggravate his symptoms was documented by the tilt table test. We reinstituted the "head-up-tilt" sleeping in his therapeutic management.