Imperforate hymen causing congenital hydrometrocolpos

A 3-day-old girl in good health was referred to our department for the evaluation of an abdominal mass detected at birth. Prenatal ultrasound (US) examinations had shown no anomaly. US examination revealed the presence of a hypoechoic and corpusculated cystic formation of about 8 × 5 × 4 cm located in the mid region of the abdomen. The uterus was not visible and the kidneys were normal with no sign of hydronephrosis. The ovaries were normal. Physical examination confirmed US findings revealing the presence of a curved membrane which covered the vaginal opening. Based on these findings, the patient was diagnosed to have hydrometrocolpos. Hymenectomy was performed and about 100 ml of milky fluid was subsequently removed by aspiration. The patient presented no other congenital anomalies and US follow-up showed a normal structure of the uterus.     

Sympathetic Neural Adaptation to Hypocaloric Diet With or Without Exercise Training in Obese Metabolic Syndrome Subjects

OBJECTIVE

Sympathetic nervous system (SNS) overactivity contributes to the pathogenesis and target organ complications of obesity. This study was conducted to examine the effects of lifestyle interventions (weight loss alone or together with exercise) on SNS function.

RESEARCH DESIGN AND METHODS

Untreated men and women (mean age 55 ± 1 year; BMI 32.3 ± 0.5 kg/m²) who fulfilled Adult Treatment Panel III metabolic syndrome criteria were randomly allocated to either dietary weight loss (WL, n = 20), dietary weight loss and moderate-intensity aerobic exercise (WL+EX, n = 20), or no treatment (control, n = 19). Whole-body norepinephrine kinetics, muscle sympathetic nerve activity by microneurography, baroreflex sensitivity, fitness (maximal oxygen consumption), metabolic, and anthropometric measurements were made at baseline and 12 weeks.

RESULTS

Body weight decreased by −7.1 ± 0.6 and −8.4 ± 1.0 kg in the WL and WL+EX groups, respectively (both P < 0.001). Fitness increased by 19 ± 4% (P < 0.001) in the WL+EX group only. Resting SNS activity decreased similarly in the WL and WL+EX groups: norepinephrine spillover by −96 ± 30 and −101 ± 34 ng/min (both P < 0.01) and muscle sympathetic nerve activity by −12 ± 6 and −19 ± 4 bursts/100 heart beats, respectively (both P < 0.01), but remained unchanged in control subjects. Blood pressure, baroreflex sensitivity, and metabolic parameters improved significantly and similarly in the two lifestyle intervention groups.

CONCLUSIONS

The addition of moderate-intensity aerobic exercise training to a weight loss program does not confer additional benefits on resting SNS activity. This suggests that weight loss is the prime mover in sympathetic neural adaptation to a hypocaloric diet.The metabolic syndrome (MetS) is an increasingly prevalent multidimensional risk factor for cardiovascular disease and type 2 diabetes (1). Its etiology is complex and incompletely understood, but thought to involve the interplay between metabolic susceptibility, lifestyle factors, and the acquisition of excess visceral adiposity (2). Scientific studies performed over the last 2 decades strongly support the relevance of the sympathetic nervous system (SNS) in both the pathogenesis and target organ complications of MetS obesity (3).Several indexes of SNS activity, such as urinary norepinephrine excretion, norepinephrine spillover from sympathetic nerves, and postganglionic muscle sympathetic nerve activity (MSNA) are increased in subjects with MetS, even in the absence of hypertension (4–7). Among the adiposity indexes, abdominal visceral fat is most strongly associated with elevated MSNA (8). Because of the bidirectional relationship between sympathetic activation and insulin resistance, much debate has focused on their chronology. Prospective studies with 10–20 years follow-up indicate that elevated plasma norepinephrine concentration (9) and sympathetic reactivity (10) precede and predict future rise in BMI and development of insulin resistance. Although seemingly counterintuitive, sympathetic activation may be causally linked to obesity via β-adrenoceptor desensitization (11) and insulin resistance (12,13). In established obesity, metabolic, cardiovascular (baroreflex impairment), and medical conditions (obstructive sleep apnea) contribute significantly to sympathetic neural drive and further aggravate insulin resistance, hence establishing a vicious cycle (3,7). Chronic sympathetic activation is associated with an increased prevalence of preclinical cardiovascular and renal changes that are recognized predictors of adverse clinical prognosis (3,14,15).Weight loss and exercise are recommended as first-line treatments for MetS. The Diabetes Prevention Program and the Oslo Diet and Exercise Study have shown the marked clinical benefits of intensive lifestyle intervention on the resolution of the MetS (16,17). Individually, both weight loss (5) and exercise training (18,19) cause sympathoinhibition and improvement in MetS components. We have previously reported that moderate weight loss (7% of body weight) by diet alone is accompanied by reductions in whole-body norepinephrine spillover and MSNA and improvement in spontaneous cardiac baroreflex function in middle-aged MetS subjects (5). Because exercise is often added to energy restriction in the treatment of obesity, it is pertinent to clarify its additive benefits. Augmented improvements in metabolic, anthropometric, and cardiovascular parameters have been observed after combined exercise training and dietary weight loss in some (17,20,21), but not other studies (22), and there are limited data regarding their combined effect on sympathetic activity (23). Exercise training may potentially augment weight loss induced sympathoinhibition by promoting a greater loss of fat relative to lean mass (20,21), by further improvement in insulin sensitivity (24) and reduction in plasma leptin concentration (21), and by potentiation of baroreceptor sensitivity (18).The present study was conducted to 1) test the hypothesis that weight loss by combined hypocaloric diet and aerobic exercise training would be associated with greater sympathoinhibition and improvement in MetS components than hypocaloric diet alone and 2) to examine the interrelationships between reduction in sympathetic tone and concurrent changes in anthropometric, metabolic (insulin sensitivity, plasma leptin concentration), and cardiovascular parameters. A moderate-intensity bicycle riding protocol was chosen as the exercise intervention, based on an earlier study that demonstrated attenuation in whole-body and renal norepinephrine spillover rates with this regimen in healthy men (19).     

The Short Cognitive Performance Test (SKT): a preliminary study of its psychometric properties in Brazil

BACKGROUND: Most instruments designed to detect dementia can lack appropriate sensitivity in the early stages of Alzheimer's disease (AD), and are subject to educational bias. The Short Cognitive Performance Test (Syndrom-Kurztest, SKT) is considered a suitable instrument to measure cognitive decline as it assesses memory, attention, and related cognitive functions, taking into account the speed of information processing. OBJECTIVES: The aim of this study was to examine the psychometric characteristics of the SKT as a dementia screening instrument in a Brazilian population sample, as compared to the Mini-mental State Examination (MMSE) and the Clock-Drawing Test (CDT). The effect of educational level on performance in the three screening tests was also verified. METHODS: Fifty-one elderly subjects were assessed. Consensus diagnoses were established by an expert multidisciplinary team, considering clinical, neuropsychological and neuroimaging data. Subjects were further classified into those with (1) mild and moderate AD, (2) non-Alzheimer's dementia, (3) mild cognitive impairment, and (4) controls, according to National Institute for Communicative Disorders and Stroke--Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) criteria. RESULTS: Statistical analyses revealed high internal consistency for the SKT (Cronbach's alpha = 0.80) and significant correlations between the total score and the SKT subscores separately (p < 0.01). Comparison of the three tests revealed strong correlations between the SKT and the MMSE (r = -0.66, p < 0.0001) and between the SKT and the CDT (r = -0.57, p < 0.0001). The SKT, MMSE and CDT scores were correlated with education. CONCLUSIONS: The Brazilian version of the SKT maintains its original psychometric properties and displays significant correlation with previously validated screening tools for dementia. Like other dementia screening tests, the SKT is subject to educational bias.     

Lifetime trauma exposure in veterans with military-related posttraumatic stress disorder: association with current symptomatology

OBJECTIVE: This study examined whether trauma exposure before, during, and/or after military service contributed to current levels of post-traumatic stress disorder (PTSD) and adjustment. Further, we investigated whether trauma exposure before military service was mediated or moderated by military trauma in its effects on current PTSD and adjustment. METHOD: In this retrospective study, archival data from the medical records of 422 male veterans diagnosed with PTSD between December 2001 and July 2004 at a Veterans Administration Medical Center PTSD clinic were analyzed. Measures included the Clinician-Administered PTSD Scale interview as well as self-report measures assessing trauma history, health problems, and general psychopathology (including PTSD). RESULTS: Findings indicated that nonmilitary-related trauma was prevalent in this sample (90%). Regression analyses for PTSD symptom severity revealed that age, greater combat exposure, and a history of physical assault after military service were significantly associated with more severe PTSD symptoms. Childhood physical abuse, adult sexual trauma, and a history of being physically assaulted during military service were also significantly associated with PTSD symptom severity. Mediational analyses indicated that childhood trauma was associated with both adult trauma and increased symptomatology on various outcome measures. Moderational analyses indicated that adult trauma exposure moderated the effect of childhood trauma exposure on health complaints. CONCLUSIONS: Results suggest that several variables, including age, greater combat exposure, and premilitary and postmilitary traumas, are associated with increased PTSD symptomatology. This finding underscores the importance of conducting a thorough assessment of trauma when diagnosing PTSD.     

Narrowing effect of off-pump CABG on the LIMA-LAD anastomosis: epicardial ultrasound assessment

AIM: Effects of off-pump CABG on LIMA-LAD anastomotic dimensions vs. on-pump CABG assessed by epicardial ultrasound imaging. MATERIAL AND METHODS: LIMA-LAD anastomoses were performed off-pump in 38 patients and on-pump in 12. Intra-operative imaging was by a GE Vivid 7 ultrasound scanner and i13L transducer. Length of the anastomosis (DA), LAD diameters at the toe (D1) and heel (D3) of the anastomosis, the reference downstream LAD (D2) were measured in diastole by two-dimensional imaging (B-mode). Relationships between these dimensions were compared between on- and off-pump patients. RESULTS: In off-pump patients, D3 dimension was smaller than D1 (p=0.004). Both D3 and D1 were smaller than D2 (p<0.01). Ratio D3/D2 was smaller than D1/D2 (p=0.009). In on-pump patients, these ratios were similar. D3/D2 ratio was smaller in off- than in on-pump patients (p=0.01), D1/D2 were similar in the two groups. CONCLUSION: Off-pump CABG may cause a narrowing of the coronaries, especially at the anastomotic heel. The anastomotic technique at the heel may have to be modified to improve its patency.     

Which cystography in the diagnosis and grading of vesicoureteral reflux?

The gold standard procedure for the evaluation of vesicoureteral reflux (VUR) is the radiographic voiding cystourethrography (VCUG); direct radionuclide voiding cystography (DRVC) is an alternative method for detecting VUR. A new imaging procedure, voiding urosonography (VUS) with contrast medium, has recently been introduced. We have carried out a comparative study of these three techniques in 157 patients (aged 6 weeks–4.7 years). VUS showed the presence of VUR in 91 of 311 renal units; VCUG detected reflux in 64 of 233 renal units, and the DRVC in 23 of 78 renal units. VCUG and VUS were compared in 118 patients, and both procedures showed the same grade of reflux in 56 refluxing units (kappa value 0.92); in six cases the reflux grade was greater at VUS than at VCUG. Seven cases of reflux detected by VUS were not identified on VCUG. VCUG did not show a grade of VUR that was higher than in VUS in any patient. In the identification of 4°–5° grade reflux, the sensitivity of VUS reached 100%. VUS and DRVC were found to be equally effective in the detection of VUR (kappa value 0.85). In conclusion, we found that VUS is a useful method for the diagnosis and grading of patients with VUR.     

Pediatric liver transplantation: the University of Padua experience

OBJECTIVE: The objective of this study was to analyze experience on pediatric liver transplantation (LT) between June 1993 and September 2006, including split liver transplantation (SLT), living donor liver transplantation (LDLT), and auxiliary partial orthotopic liver transplantation (APOLT). Furthermore, hepatocyte transplantation (HT) had a role in one patient with metabolic disease. METHODS: From November 1990 to September 2006, 657 LTs were performed including 63 pediatric LTs (9.6%) in 57 patients (32 boys and 25 girls). Six were retransplantations (9.5%). Thirty-two patients (57%) were younger than 5 years. The types of graft included the following: 26 whole organs (41%), 32 in situ split organs (51%), 4 reduced-size organs (6%), and 1 graft from a living donor (2%). Two patients received an APOLT, 4 patients received a combined kidney-liver transplantation (CKLT), and 1 patient received HT. Of the 63 pediatric LTs, 16 were behaved to be highly urgent (25%). RESULTS: Overall 1-, 3-, 5-, and 10-year patient survival rates were 82%, 82%, 78%, and 78%, respectively. Overall 1-, 3-, 5-, and 10-year graft survival rates were 76%, 76%, 72%, and 72%, respectively. In patients younger than 1 year, the 5-year survival rate was 100%. Perioperative mortality was 8.8%. Vascular complications occurred in 4 patients (6.3%). Six children required retransplantation due to primary nonfunction (PNF) in 4 cases (7%) and vascular thrombosis in 2 cases (3.5%). CONCLUSIONS: Cholestatic liver disease and age younger than 1 year were the best prognostic factors for excellent survival.     

Type I interferons in the treatment of pancreatic cancer: mechanisms of action and role of related receptors

OBJECTIVE: We evaluated the role of type I interferons (IFNs) and IFN receptors in the regulation of cell growth in 3 human pancreatic adenocarcinoma cell lines (BxPC-3, MiaPaCa-2, and Panc-1). BACKGROUND: Chemotherapy and radiotherapy have a marginal role in the management of pancreatic adenocarcinoma. The addition of IFN-alpha showed promising results in early clinical trials. METHODS: Cell proliferation and apoptosis were evaluated by DNA measurement and DNA fragmentation, respectively. Type I IFN receptor (IFNAR-1 and IFNAR-2 subunits) was determined by quantitative RT-PCR and immunocytochemistry. Cell cycle distribution was evaluated by propidium iodide staining and flow-cytometric analysis. RESULTS: The incubation with IFN-beta for 6 days showed a potent inhibitory effect on the proliferation of BxPC-3 (IC(50), 14 IU/mL) and MiaPaCa-2 (IC(50), 64 IU/mL). The inhibitory effect of IFN-beta was stronger than IFN-alpha in all 3 cell lines and mainly modulated by the stimulation of apoptosis, although cell cycle arrest was induced as well. The expression of the type I IFN receptors was significantly higher in BxPC-3 (the most sensitive cell line to IFN) and mainly localized on the membrane, whereas in Panc-1 (the most resistant cell line) about 60% to 70% of cells were negative for IFNAR-2c with a mainly cytoplasmic staining for IFNAR-2c. CONCLUSION: The antitumor activity of IFN-beta is more potent than IFN-alpha in pancreatic cancer cell lines through the induction of apoptosis. Further studies should investigate in vivo whether the intensity and distribution of IFNAR-1 and IFNAR-2c may predict the response to therapy with IFN-alpha and IFN-beta in pancreatic cancer.