[Evaluation and maintenance of heart donors]. / Evaluación y mantenimiento del donante cardíaco.

Heart transplantation is currently the best treatment option to improve hope and quality of life in patients with terminal heart failure that is refractory to conventional treatment. The scarcity of donors remains a difficult problem and is the main factor limiting the number of transplants that can be performed. Given the current situation of stagnation and disparity between the number of potential organ donors, actual donors, and patients requiring transplants, we need effective strategies to reduce the differences between supply and demand and to ensure the best possible prognosis in organ recipients. These strategies should aim to ensure optimal donor selection. Likewise, it is essential to increase the number of potential donors by widening the criteria for donation and to improve our ability to take advantage of suboptimal donors. Moreover, we need to achieve acceptable physiological maintenance of donated organs. All these actions, together with the standardization of future treatments like hormone replacement therapy and genomic evaluation, will undoubtedly lead to an increase in the rate of transplants in the short and mid term, because the option of heart transplantation continues to have only slight repercussions in the high prevalence of terminal heart failure in our environment.

Evaluación y mantenimiento del donante cardíaco / Evaluation and maintenance of heart donors

Actualmente el trasplante de corazón es la mejor opción terapéutica para aumentar la esperanza y la calidad de vida en los pacientes con insuficiencia cardíaca terminal refractaria al tratamiento convencional. La escasez de donantes es un problema difícil y pendiente de resolver, y constituye el principal factor limitante en el incremento de las cifras de trasplante. En la actual situación de estancamiento y disparidad entre el número de donantes de órganos potenciales, donantes reales y las necesidades clínicas de implantación se requieren estrategias efectivas para reducir esta diferencia y para mantener las mejores posibilidades de éxito en el pronóstico de los receptores. Estas estrategias deben ir dirigidas hacia una óptima selección del donante, así como hacia un incremento del número de potenciales donantes mediante la ampliación de los criterios de aceptación de éstos y hacia una mejora en el aprovechamiento de los donantes subóptimos. Además, debemos lograr un mantenimiento fisiológico adecuado del órgano. Todo este tipo de actuaciones, junto con la estandarización de tratamientos futuros (tratamiento hormonal de reemplazamiento o valoración genómica), nos tiene que llevar, sin duda, a un aumento en las cifras de transplantes a corto y a medio plazo, ya que la opción del transplante cardíaco sigue teniendo escasa repercusión en el gran alto grado de prevalencia de la insuficiencia cardíaca terminal en nuestro medio (AU)

Heart transplantation is currently the best treatment option to improve hope and quality of life in patients with terminal heart failure that is refractory to conventional treatment. The scarcity of donors remains a difficult problem and is the main factor limiting the number of transplants that can be performed. Given the current situation of stagnation and disparity between the number of potential organ donors, actual donors, and patients requiring transplants, we need effective strategies to reduce the differences between supply and demand and to ensure the best possible prognosis in organ recipients. These strategies should aim to ensure optimal donor selection. Likewise, it is essential to increase the number of potential donors by widening the criteria for donation and to improve our ability to take advantage of suboptimal donors. Moreover, we need to achieve acceptable physiological maintenance of donated organs. All these actions, together with the standardization of future treatments like hormone replacement therapy and genomic evaluation, will undoubtedly lead to an increase in the rate of transplants in the short and mid term, because the option of heart transplantation continues to have only slight repercussions in the high prevalence of terminal heart failure in our environment (AU)

Fibromatosis mamaria en paciente con tumorectomía previa / Breast fibromatosis in a patient with prior tumorectomy

La fibromatosis (tumor desmoide) es un tumor benigno de origen mesenquimal. La localización mamaria es excepcional y su etiología es desconocida. La fibromatosis mamaria parece, tanto clínica como radiológicamente, un carcinoma. El diagnóstico es hitológico y el tratamiento de elección es la exéresis quirúrgica. Se presenta uncaso en que el estudio histológico mostró un tumor desmoide extraabdominal, de localización mamaria, en una paciente de 23 años con antecedente de tumorectomía mamaria ipsolateral (AU)

Fibromatosis (desmoid tumors) is a rare benign mesenchytomatous proliferative process. The breast is an excepcional site. Etiology is still unknown. Fibromatosis of the breast mimics carcinoma clinically as well as radiographically. Diagnosis is made by histological studies. The treatment of choice is wide excision. We report the case of a 23-year-old woman with a previous ipsilateral breast tumorectomy (AU)

Cáncer invasivo de cérvix en España (1995). Encuesta de la Sociedad Española de Ginecología y Obstetricia / Invasive cervical cancer in Spain (1995). Survey of the Spanish Society of Obstetrics and Gynecology

Objetivos: Conocer la atención al cáncer de cérvix en España mediante una encuesta retrospectiva sobre casos de 1995 realizada por la Sección de Ginecología Oncológica y Patología Mamaria de la SEGO. Sujetos y métodos: Contestaron a la encuesta 45 hospitales que informaron de 633 casos. El número de casos por hospital osciló entre 1 y 40, siendo la mediana de 11. Pudieron procesarse 578 fichas. Resultados: La edad media de las pacientes fue de 51,2 años. El 49,3% de los casos se diagnosticó en estadio I; el 27,5% en estadio II; el 16,2% en estadio III, y el 4,6% en estadio IV. El tratamiento más empleado fue quirúrgico, mediante la intervención de Wertheim. La supervivencia a los 5 años fue del 56,4%. Conclusiones: Los factores pronósticos identificados en la evolución del cáncer de cérvix fueron el estado ganglionar, la invasión parametrial, la afección del espacio linfovascular y el tipo histológico

Objectives: To ascertain the diagnosis, treatment and outcomes of cervical carcinomas in Spain through a retrospective survey of cases diagnosed in 1995 carried out by the Oncological Gynecology and Breast Disease Section of the Spanish Society of Obstetrics and Gynecology (SEGO). Subjects and methods: Forty-five hospitals responded, providing information on 633 patients with cervical carcinoma diagnosed in 1995. The number of cases per hospital ranged between one and 40, with a median of 11. A total of 578 forms were included. Results: The mean age at diagnosis was 51.2 years. A total of 49.3% of carcinomas were in stage I, 27.5% were in stage II, 16.2% were in stage III, and 4.6% were in stage IV. The most commonly used treatment was surgery (Wertheim’s intervention). Gross 5-year survival was 56.4%. Conclusions: The prognostic factors identified were affected lymph nodes, parametrial and lymphovascular invasion, and histological subtypes

Evolución de los resultados del tratamiento del cáncer de endometrio en España entre 1980 y 1999. análisis de las casuísticas nacionales de la sociedad española de ginecología y obstetricia / Evolution of the results of treatment of endometrial cancer in Spain between 1980 and 1999. Analysis of the national casuistic of the Spanish Society of Obstetrics and Gynecology

La Sección de Ginecología Oncológica de la Sociedad Española de Obstetricia y Ginecología (SEGO) ha analizado en los últimos años las casuísticas conjuntas de numerosos hospitales del país, sobre adenocarcinoma de endometrio, por medio de dos encuestas hechas en 1991 para los casos diagnosticados y tratados entre 1980 y 1985, y en 1999 para los casos de 1993. En los aspectos fundamentales los resultados parecen ser notoriamente superiores en la encuesta más reciente, lo que debería significar que se han producido cambios importantes en el diagnóstico y en el tratamiento de estos procesos. Sin embargo, el análisis comparado de ambas encuestas, en cuya realización existen algunas deficiencias, indica que los cambios pueden haber sido menos pronunciados de lo esperado. Tanto la supervivencia global a 5 años (el 59,1 frente al 71,4 por ciento) como la supervivencia libre de enfermedad (el 55,6 frente al 63,1 por ciento) fueron estadísticamente superiores en la casuística más moderna (p = 0,0000). Los casos de la primera casuística fueron más avanzados que los de la segunda y en ellos hubo más casos diagnosticados como adenocarcinomas exclusivamente y con grado de diferenciación histológico significativamente peor. Los casos de 1993 fueron tratados primariamente con cirugía en el 88,9 por ciento de las ocasiones frente a solamente el 76,4 por ciento de los de la casuística más antigua (p = 0,0000). Solamente el 28,9 por ciento de los casos fue tratado en hospitales que atendían 25 casos o más en la primera casuística, mientras que este porcentaje ascendió al 50,5 por ciento en la casuística de 1993. En el primer período estudiado hubo más pacientes perdidas para el seguimiento que en el segundo (el 24,2 frente al 7,0 por ciento; p = 0,0000). La clasificación quirúrgica de la FIGO (1988) no parecía estar implantada todavía en 1993 pues solamente se realizó en el 27,2 por ciento de las pacientes. Estos hechos, junto con la apreciación de que las pacientes son diagnosticadas a edades tardías (61,0 ñ 9,7 años en la primera casuística y 64,0 ñ 10,5 años en la segunda), hacen considerar que la atención sobre el cáncer de endometrio en España es todavía mejorable (AU)

Changes in the rate of tubal ligation done after cesarean section.

OBJECTIVE: We studied tubal ligations done after cesarean section in a Spanish hospital during a 20-year period, in order to analyze changes in patient characteristics and indications for cesarean delivery. STUDY DESIGN: We reviewed the clinical records, for the period from 1978 to 1997, of 1996 cases of cesarean section followed by tubal ligation in 108776 births in which the fetus weighed 1000 g or more. RESULTS: During the 20-year period of study, the proportion of cesarean sections relative to vaginal deliveries increased, as did the frequency of cesarean section followed by tubal ligation relative to cesarean and vaginal deliveries. The proportion of women who underwent tubal ligation after a second cesarean section decreased from 60% during 1978-1982 to 5.6% during 1993-1997. The most frequent maternal pathology associated with gestation was previous cesarean section (60.5%), although 50% of the women had no underlying pathology. CONCLUSIONS: In our setting, the rate of cesarean section followed by tubal ligation has been increasing steadily since the early 1980s. The proportion of women who requested tubal sterilization and who had only one living child, or who had had a previous cesarean birth, also increased.

Lipid effects, effectiveness and acceptability of tibolone versus transdermic 17 beta-estradiol for hormonal replacement therapy in women with surgical menopause.

OBJECTIVE: To compare the effectiveness of tibolone and 17 beta-estradiol on climacteric symptoms, lipid and biochemical parameters in women with surgical menopause. METHODS: In a prospective randomised clinical trial group comparative study, the effects on the aforementioned parameters, as well as treatment compliance and side effects were studied with oral tibolone 2.5 mg per day and with transdermic 17 beta-estradiol at 50 microg per day for a period of 12 months. Statistical analysis was carried out using the Fisher-test, analysis of the variance (ANOVA) for the two factors and the Bouferoni test. RESULTS: Lipid metabolism analysis showed lower levels of HDL and triglycerides in the tibolone group. Other biochemical parameters were not affected. Similar reductions in climacteric symptoms were found in both the groups, but the tibolone group revealed a greater improvement in psychological problems and in sexual behaviour. No differences were observed with respect to compliance and side effects. CONCLUSIONS: Tibolone is as effective or more than 17 beta-estradiol in reducing climacteric symptoms, and shows greater triglyceride and total cholesterol improvements. Tibolone is a good alternative to estrogens in women with surgical menopause.

Tumores epiteliales de bajo potencial maligno del ovario. Estudio multicéntrico retrospectivo de 162 casos / Ovarían epithelial tumors with low malignant potential. Multicenter retrospective study of 162 cases

Objetivo: Estudiar los casos de tumor epitelial de bajo potencial maligno del ovario tratados en cuatro instituciones españolas dedicadas a la ginecología oncológica.Material y métodos: Estudio retrospectivo de 162 pacientes tratadas entre el 20 de octubre de 1977 y el 23 de octubre de 1997 por tumor epitelial ovarico de bajo potencial maligno, analizándose estadio FIGO, histologia, tipo de tratamiento y supervivencia.Resultados: La mayoría de las pacientes se diagnosticaron en estadio 1, el tipo histológico más frecuente fue el mucinoso y la supervivencia actuarial global fue del 97,1 por ciento a 63 meses de seguimiento. Las pacientes tratadas con cirugía y quimioterapia tuvieron peor supervivencia, pero el porcentaje de estadios avanzados en este grupo era mayor que en el grupo tratado sólo con cirugía. Se registraron cuatro fallecimientos en el período de seguimiento. Conclusiones: La cirugía es el tratamiento de elección, pudiendo ser conservadora en caso de pacientes jóvenes con deseo genésico y estadio I. La cirugía subóptima y los implantes invasivos marcan negativamente el pronóstico. El tratamiento quimioterápico adyuvante sólo parece indicado cuando existen factores de mal pronóstico y estadios avanzados (AU)

Sarcomas uterinos / Uterine sarcomas

Objetivo: Se estudian 165 casos de sarcomas uterinos diagnosticados en los hospitales del Grupo Oncológico Ginecológico Español (GOGE).Sujetos y métodos: La distribución según tipos histológicos fue: leiomiosarcomas (35,2 por 100), sarcomas del estroma endometrial (28,5 por 100), tumores mullerianos mixtos malignos (TMMM) homólogos (23,0 por 100) y heterólogos (13,3 por 100). Se analiza la edad, menopausia, paridad, síntoma inicial, tiempo de consulta, métodos diagnósticos, distribución por estadios, tratamiento y seguimiento. El síntoma inicial más frecuente fue la hemorragia vaginal (77,6 por 100). El diagnóstico previo a la cirugía fue del 63,6 por 100.Resultados: La supervivencia global a los tres y cinco años fue del 55,4 y 47,7 por 100. Se produjo persistencia o recaída de la enfemedad en el 49,7 por 100 de los casos, con un tiempo medio de aparición de la recurrencia de 23,1 meses.Conclusiones: Los factores fundamentales que determinaron la supervivencia fueron la afectación miometrial, la propagación extrauterina y la edad de las pacientes (AU)

Successful pregnancy in a woman with acromegaly treated with somatostatin analog (octreotide) prior to surgical resection.

A 27-year-old woman with a GH-secreting pituitary macroadenoma was treated with continuous s.c. infusion of octreotide prior to surgical resection. Subsequently, she was found to be 6 months pregnant. Fetal echographs were normal, the newborn had no malformation, and postnatal development was normal.

Tumour necrosis factor-alpha and interleukin-1 and -6 in fibrocystic breast disease.

The risk of developing breast cancer is higher in women presenting gross cystic disease (cysts > 3 mm in diameter) of the breast with intracystic K+/Na+ > 3 as compared with K+/Na+ < 3. The present study reports the levels of tumour necrosis factor-alpha (TNF-alpha), interleukin-1 (IL-1), and interleukin-6 (IL-6) in the breast cyst fluid of women with gross cystic disease and analyses the relationship between the intracystic concentration of these cytokines, sex steroid hormones, and the K+/Na+ ratio. The concentration of these cytokines, estradiol, testosterone, dehydroepiandrosterone sulfate (DHEA-S), and 17-OH-progesterone were determined in the breast cyst fluid of 54 women with gross cystic disease. No significant differences were found in the cystic levels of IL-1 between cysts with intracystic K+/Na+ < 3 and > 3. However, in cysts with intracystic K+/Na+ > 3 we found a lower concentration of IL-6 and TNF-alpha than in those with intracystic K+/Na+ < 3. Stepwise multiple linear regression analysis demonstrated that the concentration of IL-6 in breast cyst fluid was predicted statistically by a negative regression coefficient for the concentration of estradiol and DHEA-S, and by a positive regression coefficient for the concentration of TNF-alpha. The concentration of TNF-alpha in breast cyst fluid was predicted statistically by a positive regression coefficient for the concentration of IL-6, and by a negative regression coefficient for the concentration of estradiol. No candidate variable was included in the model to predict concentrations of IL-1 in breast cyst fluid. Our results indicate that IL-6 and TNF-alpha could have a local 'protector' role in gross cystic disease, and that they could be used as a marker to identify cyst type.

Amnioinfusion in term labor with low amniotic fluid due to rupture of membranes: a new indication.

OBJECTIVE: The null hypothesis was that the use of intrapartum amnioinfusion to induce term labor because of premature rupture of membranes when labor was complicated by low amniotic fluid volume due to vaginal loss would not improve fetal heart rate patterns, decrease the incidence of operative delivery, or improve neonatal acid-base status. STUDY DESIGN: 200 term pregnancies with low amniotic fluid due to vaginal loss were randomly chosen to receive intrapartum amnioinfusion or standard obstetric care without amnioinfusion. Fetal heart rate pattern, method of delivery and neonatal acid-base status were compared with Student's t test, chi-squared analysis, Mann-Whitney U- or Fisher's exact test. RESULTS: When amnioinfusion was used, the fetuses had lower rates of variable (74 vs. 91%, P<0.01) or late (26 vs. 58%, P<0.001) decelerations. Spontaneous deliveries were more frequent (77 vs. 59%, P<0.01) and cesarean sections less frequent (3 vs. 10%, P<0.05). Mean umbilical arterial (7.24+/-0.07 vs. 7.21+/-0.08, P<0.01) and venous (7.31+/-0.06 vs. 7.28+/-0.08, P<0.01) pH were significantly higher in newborns with amnioinfusion, and babies in this group had lower rates of neonatal acidemia of arterial (22 vs. 36%, P<0.005) or venous (13 vs. 26%, P<0.005) origin. CONCLUSIONS: Amnioinfusion improved fetal heart rate pattern, lowered the incidence of operative delivery, and improved neonatal acid-base status in term labor complicated by low amniotic fluid due to vaginal loss.

Amnioinfusion in labor induction of term pregnancies with premature rupture of the membranes and low amniotic fluid.

OBJECTIVE: To analyze the utility of prophylactic amnioinfusion in term pregnancies with PROM and a low amniotic fluid index during labor induction. METHOD: Forty-two women with amnioinfusion and 42 in a control group with amniotic fluid index (AFI) below 10 cm when admitted to labor induction were studied. All patients had electronic fetal heart rate and intrauterine pressure continuous monitoring. Amnioinfusion of normal saline (37 degrees C) was realized in the study group, using a continuous perfusion pump at 600 ml/h for 1 h, after which the AFI was again recorded; if this was < 15, the perfusion was continued at 180 ml/h until full cervical dilatation was achieved or until uterine baseline activity reached 20 mm Hg. The control group received identical obstetric care except in respect of amnioinfusion. RESULT: Both groups were similar in age, primiparity, gestational age, initial AFI, interval from rupture of membranes until delivery and length of labor. The amnioinfusion of 600 ml in 1 h significantly increased the AFI (an increase of 7.2 +/- 3.9 vs. a decrease of 1.1 +/- 1.6, P < 0.01). In the amnioinfusion group, there was a significantly lower rate of cesarean deliveries (0 vs. 6, P < 0.05) and a better mean umbilical arterial pH at delivery (7.24 +/- 0.07 vs. 7.21 +/- 0.08, P < 0.05). No differences were observed in maternal or neonatal hospitalization days or infectious morbidity. CONCLUSION: It is concluded that prophylactic amnioinfusion improves neonatal metabolic state when used in labor induction of term pregnancies with PROM and a low amniotic fluid index.

Increase of large granular lymphocytes in human ejaculate containing antisperm antibodies.

Using flow cytometry, we studied the expression of the CD16 antigen by lymphocytes present in human semen samples from three groups of patients: 60 fertile men attending for vasectomy, 60 sterile patients without antisperm antibodies (ASA) and 18 immunological sterile patients with ASA in their ejaculate. No significant difference was found in the concentration of leukocytes or subpopulations of these cells (monocytes, lymphocytes and granulocytes) between fertile, sterile without ASA and immunological sterile groups. However, we detected a predominance of macrophages/monocytes within the population of seminal leukocytes. No statistically significant difference was found in the absolute number of T and B lymphocytes between the three groups studied. However, a significant increase in the number of CD16+ lymphocytes was observed in the ejaculate of sterile patients with ASA as compared to the other groups. This finding might establish an important parameter in the follow-up and prognosis of patients with immunological sterility.

Timing of intrapartum ampicillin and prevention of vertical transmission of group B streptococcus.

OBJECTIVE: To evaluate the relationship between the time elapsed from the administration of ampicillin prophylaxis to delivery and its efficacy in interrupting intrapartum transmission of group B streptococcus. METHODS: During the 12-month study period, all women who came to the Virgen de las Nieves Hospital (Granada, Spain) for delivery were screened for group B streptococcus vaginal carriage by a pigment-detection culture-based procedure. Colonized women were treated with ampicillin (2 g intravenously), and the interval between ampicillin administration and delivery was recorded. Newborns from colonized mothers also were screened to detect group B streptococcus colonization. RESULTS: During the study period, 4525 women were admitted to the hospital for delivery and screened for group B streptococcus vaginal colonization. Group B streptococcus was detected in 543 women (12%), of whom 454 gave birth vaginally to 454 liveborn infants. Intrapartum ampicillin was given to 201 of these 454 women (44%), and 10% of the newborns from mothers who received intrapartum ampicillin prophylaxis were colonized by group B streptococcus. The relationship between timing of ampicillin administration and rate of neonatal group B streptococcal transmission was as follows: less than 1 hour before delivery, 46%; 1-2 hours, 29%; 2-4 hours, 2.9%; and more than 4 hours, 1.2%. Among the 253 mothers who received no intrapartum prophylaxis, colonization was found in 120 of their newborns (47%). CONCLUSION: When the time between the start of ampicillin prophylaxis and delivery is at least 2 hours, vertical transmission of group B streptococcus is minimized.

Comparison of the efficacy and tolerability of dexketoprofen and ketoprofen in the treatment of primary dysmenorrhea.

Dexketoprofen, the pure S(+)-enantiomer of ketoprofen, is a promising new analgesic, but few clinical trials have yet examined its efficacy and tolerability. In this study, patients with a history of primary dysmenorrhea were treated with dexketoprofen doses of 12.5 and 25 mg, ketoprofen 50 mg, and placebo using a randomized, four-way crossover design. Efficacy analyses showed that dexketoprofen 12.5 and 25 mg and racemic ketoprofen 50 mg significantly reduced pain intensity compared with placebo from 1 h after dose to 4-6 h after dose. Interestingly, dexketoprofen at 12.5 mg was significantly superior to placebo at 30 min after dose. Mean pain relief scores also demonstrated that both doses of dexketoprofen and racemic ketoprofen were significantly superior to placebo at 1-6 h after the first dose. No indices of analgesic efficacy showed any significant differences between the two doses of dexketoprofen or between dexketoprofen and ketoprofen. After repeated dose administration, similar results were obtained. There were no significant effects of any treatment on activities of daily living, menstrual flow, or associated symptoms. Dexketoprofen was effective, well tolerated, and had no difference in the incidence of adverse events compared to ketoprofen or placebo.

High frequency of altered HLA class I phenotypes in invasive breast carcinomas.

We studied 105 tumor samples obtained from patients diagnosed as having breast carcinomas for HLA class I and II (DR) antigen expression, using a panel of mAbs defining HLA-monomorphic, locus-specific and allele-specific determinants. Peripheral blood lymphocytes from patients were also typed for HLA alleles. The results indicated total HLA class I losses in 55 patients (52.3%), HLA-A locus losses in four patients (3.8%), HLA-B locus losses in eight patients (7.6%), and A, B, locus losses in 10 patients (9.5%). The remaining 28 patients whose tissues reacted positively with monomorphic- and locus-specific mAbs were tested for HLA allelic losses using several anti-HLA mAbs defining A2, A3, A9, B8, B12, etc. Of these 28 patients, 16 (57%) showed one or more losses of HLA reactivity. These results indicated that in 88.5% of patients we detected a particular HLA-altered tumor phenotype. The downregulation of HLA class I antigens in breast carcinomas may thus be more frequent than previously reported, and patients without HLA class I downregulation may be the exception rather than the rule. It cannot be ruled out that HLA alterations are present in some of the 12 patients with an apparently normal HLA phenotype, as some HLA alleles could not be studied because of the lack of appropriate mAbs. These HLA alterations could represent an important step associated with tumor invasion, conferring to the tumor cells the ability to escape from T-lymphocyte recognition.

Influence of obstetric and perinatal care on perinatal mortality.

OBJECTIVE: Cases of perinatal death attributed to suboptimal perinatal care between 1979 and 1992 inclusive at a large, tertiary care center are reviewed. STUDY DESIGN: The study compared two periods: 1979-1985 and 1986-1992. The perinatal morbidity-mortality committee analyzed patient records for the mothers and neonates, delivery room records, the results of fetal autopsy, and histological sections of the placenta. RESULTS: In the first period, 21.5% of the deaths were found to have received suboptimal care; this figure declined 13.5% in the second period (P < 0.05). During the second period, antenatal, intranatal and postnatal care improved, as shown by the lower suboptimal care rate for antepartum (15.8% versus 9.8%; P < 0.05), intrapartum (49.2% versus 22.1%; P < 0.001) and postpartum death (19.9% versus 8.1%; P < 0.001). During both periods, fetal death during pregnancy made up the largest proportion of deaths attributed to suboptimal care, with 44 cases (43.1%) during 1979-1985, and 36 cases (64.3%) during 1986-1992 (P < 0.01). Of these cases, fetuses with intrauterine growth retardation were the most frequent recipients of suboptimal care (20 cases (45.5%) during the first period; 18 cases (50%) during the second period). CONCLUSION: Despite better prenatal care, the highest suboptimal care rate was due to suboptimal care during pregnancy, when some high risk situations were overlooked by the obstetrician.

CD4+ cells in human ejaculates.

Using flow cytometry, we studied the expression of the CD4 antigen within the different cells present in human ejaculate, both in spermatozoa and round cells. In all, 20 samples of semen were obtained from fertile males; in 11 of these, we detected the presence of leukocytes, using the peroxidase test. Swim-up was performed for the analysis of the spermatozoa. From our results it may be concluded that there is no expression of the CD4 antigen on the surface of human spermatozoa or on CD45- ejaculate cells (epithelial and germinal cells). However, we did detect the presence of the CD4 antigen on the surface of the leukocyte cells (CD45+). A better characterization of these CD45+ cells made it apparent that the CD4+ cells of ejaculate are composed of T lymphocytes (helper/inducer T lymphocytes) and monocytes. Thus we may conclude that human spermatozoa do not express the CD4 antigen, the cell surface receptor for human immunodeficiency virus. However, we did detect CD4+ T lymphocytes and CD4+ monocytes in semen.