Third-trimester ultrasound for antenatal diagnosis of placenta accreta spectrum in women with placenta previa: results from the ADoPAD study.

OBJECTIVE: To evaluate the performance of third-trimester ultrasound for the diagnosis of clinically significant placenta accreta spectrum disorder (PAS) in women with low-lying placenta or placenta previa. METHODS: This was a prospective multicenter study of pregnant women aged ≥ 18 years who were diagnosed with low-lying placenta (< 20 mm from the internal cervical os) or placenta previa (covering the internal cervical os) on ultrasound at ≥ 26 + 0 weeks' gestation, between October 2014 and January 2019. Ultrasound suspicion of PAS was raised in the presence of at least one of these signs on grayscale ultrasound: (1) obliteration of the hypoechogenic space between the uterus and the placenta; (2) interruption of the hyperechogenic interface between the uterine serosa and the bladder wall; (3) abnormal placental lacunae. Histopathological examinations were performed according to a predefined protocol, with pathologists blinded to the ultrasound findings. To assess the ability of ultrasound to detect clinically significant PAS, a composite outcome comprising the need for active management at delivery and histopathological confirmation of PAS was considered the reference standard. PAS was considered to be clinically significant if, in addition to histological confirmation, at least one of these procedures was carried out after delivery: use of hemostatic intrauterine balloon, compressive uterine suture, peripartum hysterectomy, uterine/hypogastric artery ligation or uterine artery embolization. The diagnostic performance of each ultrasound sign for clinically significant PAS was evaluated in all women and in the subgroup who had at least one previous Cesarean section and anterior placenta. Post-test probability was assessed using Fagan nomograms. RESULTS: A total of 568 women underwent transabdominal and transvaginal ultrasound examinations during the study period. Of these, 95 delivered in local hospitals, and placental pathology according to the study protocol was therefore not available. Among the 473 women for whom placental pathology was available, clinically significant PAS was diagnosed in 99 (21%), comprising 36 cases of placenta accreta, 19 of placenta increta and 44 of placenta percreta. The median gestational age at the time of ultrasound assessment was 31.4 (interquartile range, 28.6-34.4) weeks. A normal hypoechogenic space between the uterus and the placenta reduced the post-test probability of clinically significant PAS from 21% to 5% in women with low-lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 9% in the subgroup with previous Cesarean section and anterior placenta. The absence of placental lacunae reduced the post-test probability of clinically significant PAS from 21% to 9% in women with low-lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 36% in the subgroup with previous Cesarean section and anterior placenta. When abnormal placental lacunae were seen on ultrasound, the post-test probability of clinically significant PAS increased from 21% to 59% in the whole cohort and from 62% to 78% in the subgroup with previous Cesarean section and anterior placenta. An interrupted hyperechogenic interface between the uterine serosa and bladder wall increased the post-test probability for clinically significant PAS from 21% to 85% in women with low-lying placenta or placenta previa and from 62% to 88% in the subgroup with previous Cesarean section and anterior placenta. When all three sonographic markers were present, the post-test probability for clinically significant PAS increased from 21% to 89% in the whole cohort and from 62% to 92% in the subgroup with previous Cesarean section and anterior placenta. CONCLUSIONS: Grayscale ultrasound has good diagnostic performance to identify pregnancies at low risk of PAS in a high-risk population of women with low-lying placenta or placenta previa. Ultrasound may be safely used to guide management decisions and concentrate resources on patients with higher risk of clinically significant PAS. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Voltage-Gated Sodium Channels: Evolutionary History and Distinctive Sequence Features.

Voltage-gated sodium channels (Nav) are responsible for the rising phase of the action potential. Their role in electrical signal transmission is so relevant that their emergence is believed to be one of the crucial factors enabling development of nervous system. The presence of voltage-gated sodium-selective channels in bacteria (BacNav) has raised questions concerning the evolutionary history of the ones in animals. Here we review some of the milestones in the field of Nav phylogenetic analysis and discuss some of the most important sequence features that distinguish these channels from voltage-gated potassium channels and transient receptor potential channels.

Optimal fluxes, reaction replaceability, and response to enzymopathies in the human red blood cell.

Characterizing the capabilities, key dependencies, and response to perturbations of genome-scale metabolic networks is a basic problem with important applications. A key question concerns the identification of the potentially most harmful reaction knockouts. The integration of combinatorial methods with sampling techniques to explore the space of viable flux states may provide crucial insights on this issue. We assess the replaceability of every metabolic conversion in the human red blood cell by enumerating the alternative paths from substrate to product, obtaining a complete map of he potential damage of single enzymopathies. Sampling the space of optimal steady state fluxes in the healthy and in the mutated cell reveals both correlations and complementarity between topologic and dynamical aspects.

[Differential diagnostic problems in metastatic ovarian tumors of intestinal origin. Description of a clinical case]. / Problemi diagnostici differenziali dei tumori ovarici metastatici di origine intestinale. Descrizione di un caso clinico.

The authors report the case of a patient undergoing gynecological surgery to the presence of a right ovarian mass with a maximum of diameter of 23 cm which was found to be a secondary tumour. Histologically analysis showed that this mass was the metastasis of a tumour of intestinal origin, a finding that was then confirmed by flow cytometry. The authors draw attention to the need for patients with suspected ovarian tumour to undergo preoperative diagnostic tests to evaluate the possibility of neoplastic pathology in the gastrointestinal tract in order to optimise surgery and antiblastic treatment.

Prolonged streptokinase infusion in patients with unstable angina: results of a randomized, placebo-controlled clinical trial.

BACKGROUND: The purpose of this study was to assess the efficacy both of prolonged (48 h) and of short-duration (1 h) administrations of streptokinase in patients with unstable angina. In unstable angina, thrombosis is a dynamic process that waxes and wanes for hours and even days. The majority of previous studies have investigated the efficacy of short-duration thrombolytic regimens. METHODS: One hundred patients with acute unstable angina were randomly allocated to receive placebo, 1,500,000 U streptokinase during 1 h or 250,000 U streptokinase during 1 h and then a prolonged infusion of 100,000 U for the next 48 h. All of the treatments included intravenous heparin administration for 72 h. RESULTS: No death occurred in the study population. One of 34 patients treated with placebo (2.9%), three of 33 treated with streptokinase during 1 h (9.0%) and three of 33 treated with streptokinase during 48 h (9.0%) had a myocardial infarction. Refractory angina occurred in nine, three and seven patients receiving placebo, streptokinase during 1 h and streptokinase during 48 h, respectively. Kaplan-Meier analysis showed that the total probability for a patient to be free of cumulative events did not differ among the three groups of patients (NS). Fourteen patients (41%) receiving placebo, 15 patients (45%) receiving streptokinase during 1 h and 14 patients (42%) receiving streptokinase during 48 h had ischaemic episodes detected by Holter monitoring during the first 72 h after hospital admission (NS). Two patients receiving streptokinase during 48 h required blood transfusion, and a greater incidence of minor bleeding (P < 0.05) and adverse events (P < 0.02) was observed in patients receiving prolonged streptokinase administration than in those receiving streptokinase during 1 h or placebo. CONCLUSIONS: In patients with acute unstable angina, the administration of two different regimens of streptokinase significantly reduces the probability neither of developing cardiac events during hospitalization nor of ischaemia detected by Holter monitoring in the early phase after hospital admission. Although the sample size of the study provided sufficient power to exclude only a large difference in effect size, it did allow us to detect a significantly higher incidence of bleeding in the group of patients treated with prolonged streptokinase infusion.

Early predictors of smoking cessation after myocardial infarction.

The determinants of long-term smoking cessation were evaluated in 80 patients who smoked cigarettes and survived a myocardial infarction. All patients underwent a program of rehabilitation and secondary prevention including in-hospital counseling and physician-guided reinforcing sessions at 1, 3, and 6 months after discharge. At 18 months of follow-up, 53 patients (66.3%) had quit smoking. Variables associated with smoking cessation were duration of hospital stay greater than or equal to 19 days (79 vs. 48%; p less than 0.005) and peak creatine phosphokinase (CPK) elevation greater than or equal to 500 U/l (76 vs. 54%; p less than 0.05). Males tended to quit in higher proportion than females (68 vs. 44%). Age, prior myocardial infarction, other cardiovascular risk factors, infarction location, Killip class at entry, and duration of stay in coronary care unit did not significantly affect the quitting rates. Logistic regression analysis singled out the duration of hospital stay as a significant predictor of smoking cessation (p less than 0.005). Early and intensive secondary prevention during the hospital stay is crucial in promoting sustained smoking cessation after myocardial infarction.

Effect of therapy with streptokinase, diltiazem, and heparin on ventricular arrhythmias in unstable angina.

We evaluated the effect of three different anti-ischemic therapeutic regimens on ventricular arrhythmias in 25 patients hospitalized for unstable angina. All patients were randomized to receive (in addition to infusion of heparin, diltiazem, and nitrates), either placebo, or streptokinase (SK) 1,500,000 U in 1 h, or SK 250,000 U in 30 min followed by 100,000 U/h for 48 h. Patients underwent ECG monitoring during the first 72 h after admission and for 24 h after 15 days of oral therapy with diltiazem, aspirin, and transdermal nitrates. Premature ventricular complexes (PVC) and ventricular tachycardia episodes (VT) were significantly reduced during the early phase of hospitalization and after 15 days, in patients treated with prolonged SK infusion. Ventricular arrhythmias are a frequent finding in unstable angina; they are correlated neither to the severity of coronary disease nor to ventricular function; prolonged infusion of SK added to heparin, diltiazem, and nitrates seems to reduce the number and severity of ventricular arrhythmias.

De novo (15;21) unbalanced translocation of paternal origin in a girl with Prader-Willi syndrome.

We describe a 3-month-old girl with Prader-Willi syndrome and a de novo unbalanced karyotype 45,XX,t(15;21)(q13;q22.3). This rearrangement, resulting in monosomy for the pericentromeric region of chromosome 15 and a virtual monosomy for the 21q distal band, had a paternal origin as demonstrated by Q and NOR staining.

Reduced HDL2 levels in myocardial infarction patients without risk factors for atherosclerosis.

Out of a total of 170 patients with a first myocardial infarction, aged below 65 years, consecutively admitted to the Coronary Care Unit of a large urban hospital, only 14 did not present with any risk factor(s) for atherosclerosis (smoking, hypertension, diabetes and obesity). None of these 14 patients showed significant hyperlipidemia. Compared to a control series of normal individuals of the same age (50.0 +/- 5.8 years for males and 61.6 +/- 3.0 years for females), they showed a significant reduction of high-density lipoprotein (HDL)-cholesterol and of apolipoprotein A-I (respectively -18.2 and -9.5%). However, the most striking abnormality was a 30% decrease of the HDL2 mass and of HDL2 cholesterol; both HDL2 and HDL3 had a reduced cholesteryl ester content in the patients. Reduced HDL2 mass and cholesterol levels in plasma, accompanied by significant alterations in HDL subfraction composition, are consistent with a defective cholesterol esterification in HDL. HDL2 deficiency may be a primary alteration in myocardial infarction patients without other significant risk factors.

Polychemotherapeutic treatment for ovarian carcinoma (our experience).

Since September 1980 to June 1983 we have treated 32 patients with ovarian cancer. Most patients were submitted to time polychemotherapy cyclophosphamide, adriamycin and cis-platinum. The maximum of survival time was 24 months; six patients died; the period of survival of the remaining 24 patients is between 2 and months.