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Coronavirus disease (COVID-19) may predispose patients to pulmonary embolism (PE), despite standard thromboprophylaxis. Our retrospective study aimed to report the prevalence of PE in patients with COVID-19 and severe respiratory failure (SRF) treated with intermediate- to full-dose enoxaparin. We analyzed data from patients with COVID-19 pneumonia and SRF admitted to our Respiratory Intensive Care Unit (RICU) from February 27 to April 20, 2020. All patients received at least intermediate-dose enoxaparin (40 mg twice daily). Computed tomography pulmonary angiography (CTPA) was used to detect PE. Ninety-two patients with COVID-19 pneumonia and SRF were admitted to our RICU. Twenty-two patients underwent CTPA (24 %), 11 of whom had PEs (12%). We hypothesize that the enoxaparin treatment may be responsible for the lower prevalence of PE as compared to previous reports of similar patients, even if our report had several limitations, mainly the small sample size.

The World Health Organization (WHO) declared Sars-CoV infection and COVID-19 as a pandemic and global emergency. In addition to viral pneumonia and the severe acute respiratory syndrome (Sars), the heart is affected in some patients due to the detection of biomarkers and reported cases of myocarditis and pericarditis. Therefore, the knowledge of electrocardiogram presentation of these actual infections can guide the choice for the best treatment and can help to reduce misdiagnosis, mainly the acute myocardial infarction, which is the main differential diagnosis.

A 50-year-old female patient admitted for etiological syncope investigation. A 24-hour Holter was installed where the record showed the mechanism of sudden cardiac death. Sudden bradycardia caused by paroxysmal atrioventricular block led to torsades de pointes, ventricular fibrillation and death. This case shows the importance of Holter in the chronology of arrhythmic events that lead to sudden death and highlights a poorly reported event – the occurrence of cardiac death during 24-hour Holter monitoring.

Brugada syndrome is an autosomal dominant heart disease caused by dysfunctions in the ionic channels, whose carriers present a classic electrocardiographic pattern and predisposition to malignant ventricular arrhythmias. The electrocardiogram alterations may be dynamic, spontaneous, or induced by sodium channel blocking drugs (ajmaline, procainamide, etc.). However, electrocardiographic findings that diagnose Brugada syndrome may occur even in the absence of congenital dysfunction of ionic channels, characterizing “Brugada phenocopy”, therefore the exclusion of secondary causes is fundamental for the correct diagnosis of channelopathy.

Objective: To determine the incidence of postoperative atrial fibrillation (PAF) of cardiac surgery, its impact on morbimortality and duration of hospital stay in a tertiary cardiology center of the state of Santa Catarina, Brazil. Methods: Cohort study with 134 adult patients submitted to cardiac surgery. Results: the incidence was 32.8%. After multivariate analysis, patients who did not receive beta-blockers were associated with PAF with a relative risk odds ratio (RR) 10.73 (p

Objetivo: Determinar a incidência de fibrilação atrial no pós-operatório (FAPO) de cirurgia cardíaca, seu impacto sobre a morbimortalidade e o tempo de internação hospitalar em um centro terciário de cardiologia do estado de Santa Catarina, Brasil. Métodos: Estudo de coorte com 134 pacientes adultos submetidos à cirurgia cardíaca. Resultados: A incidência foi de 32,8%. Após análise multivariada, os pacientes que não receberam betabloqueador estiveram associados à FAPO com razão de chances risco relativo (RR) 10,73 (p < 0,001). A maior taxa de eventos cardiovasculares (acidente vascular cerebral, mortalidade e síndrome coronariana aguda) foi de 25% no grupo FAPO vs. 10% (RR 3,21; p = 0,035) o que, consequentemente, gerou tempo de internação maior nesses pacientes (19,1 vs. 12,5; p = 0,01). Conclusão: A incidência de FAPO foi elevada, ocasionou significativo aumento de morbimortalidade e tempo de internação hospitalar e consolidou o papel da terapia betabloqueadora na sua prevenção, podendo servir como base a futuras políticas de prevenção dessa intercorrência.

Background: Coronavirus disease 2019 (COVID-19) may predispose patients to venous thromboembolism (VTE) due to inflammation, hypoxia, immobilization, and diffuse intravascular coagulation, despite standard thrombopropylaxis. Our retrospective study reports the incidence of pulmonary embolism (PE) in patients with COVID-19 and severe respiratory failure(SRF) treated with intermediate to full-dose enoxaparin. .Methods: This retrospective case series analysed data from patients with COVID-19 pneumonia and severe respiratory failure (SRF) admitted to our Respiratory Intensive Care Unit (RICU) between February 27 and April 20, 2020 for non-invasive positive-pressure ventilation. All patients received at least intermediate-dose enoxaparin (40 mg twice daily). If PE was suspected or diagnosed, patients were treated with full-dose enoxaparin (1 mg/kg twice daily). Computed tomography pulmonary angiography (CTPA) was used to detect PE in patients with elevated D-dimer levels (> 3000 ng/mL) and/or other clinical indicators, including sudden worsening of cardiopulmonary status.Results: Ninety-two patients (71 males, 21 females; mean age 58 ± 11 years) with COVID-19 pneumonia and SRF (mean arterial oxygen partial pressure/fractional inspired oxygen [PaO2/FiO2] of 143 ± 45 mm Hg) were admitted to our RICU. Twenty-two patients underwent CTPA (24%), with PEs detected in 11 (12%). Mean PaO2/FiO2 and mean D-dimer levels did not significantly differ between patients with or without PE. Eleven patients (12%) died in the hospital, with a mean age of 70 ± 11 years for deceased patients and 56 ± 11 years for surviving patients (p < 0.0001).Conclusions: PE was diagnosed in 12% of patients despite intermediate to full-dose enoxaparin treatment. However the incidence of PE in our patients was lower than that previously reported. We hypothesize that this reduced PE incidence may have been secondary to the higher than prophylactic enoxaparin dose that was used.

This work describes the new facility for applied nuclear physics at the University of Sao Paulo, mainly for irradiation of electronic devices. It is a setup composed of a quadrupole doublet for beam focusing/defocusing plus multiple scattering through gold foils to produce low intensity, large-area, and high-uniformity heavy-ion beams from 1H to 107Ag. Beam intensities can be easily adjusted from 102 particles cm2/s to hundreds of nA for an area as large as 2.0 cm2 and uniformity better than 90%. Its irradiation chamber has a high-precision motorized stage, and the system is controlled by a LabViewTM environment, allowing measurement automation. Design considerations and examples of use are presented Este trabalho descreve as novas instalações de física nuclear aplicada da Universidade de São Paulo, principalmente para irradiação de dispositivos eletrônicos. É uma configuração composta por um quadrupolo dupleto para foco / desfoque de feixe mais espalhamento múltiplo através de folhas de ouro para produzir feixes de íons pesados ​​de baixa intensidade, grande área e alta uniformidade de 1 H a 107 Ag. As intensidades do feixe podem ser facilmente ajustadas de 10 2 partículas cm 2 / s a ​​centenas de nA para uma área tão grande quanto 2,0 cm 2 e uniformidade melhor que 90%. Sua câmara de irradiação possui estágio motorizado de alta precisão, e o sistema é controlado por um LabView TMambiente, permitindo a automação da medição. São apresentadas considerações de design e exemplos de uso. 91 5 053301

Objective: To identify the profile of patients who implanted pacemakers and their complications in a tertiary cardiology center in the state of Santa Catarina. Methods: Unicentric, observational and prospective study with 81 patients submitted to pacemaker implantation by the Cardiovascular Surgery Service. Results: Provisional pacemaker was necessary in 42 cases (51.8%) and the average time of temporary pacemaker insertion was 2.2 days. Death occurred in 3 patients (3.7%), however only 1 case (1.2%) was associated with the implant. Conclusion: The clinical characteristics and indications of the implant in the study population were similar to those found in the literature, however the number of complications was high and the length of stay of the provisional pacemaker is beyond that recommended.

Objective We have conducted a longitudinal observational study in order to evaluate the prevalence and the incidence of depressive and anxious symptoms in women and men seeking infertility treatment and to analyze associated factors or risk factors for these kinds of disorders. Study design A total of 1000 consecutive couples that visited our center for the first time were asked to join this study. Depressive and anxious symptoms were assessed with self-rating Zung Depression Scale (ZDS) and Zung Anxiety Scale (ZAS) questionnaires. A second assessment was planned at the time of β HCG dosage (or at the moment of cycle suspension). A standard questionnaire was used to investigate socio-demographic information and the psychological aspects of couples undergoing in vitro fertilization (IVF) treatment. The fertility history and outcome of IVF treatment were collected from patients’ medical records. Results 14.7% of women had anxious symptoms and 17.9% depressive symptoms, whereas 4.5% of men had anxious symptoms and 6.9% depressive symptoms. Women with depressive and anxious symptoms were younger, more often had an anxious partner and had a longer history of infertility. Men with depressive and anxious symptoms more frequently had a temporary job, they had an anxious partner and they were more frequently at the first in vitro fertilization (IVF) cycle. The incidence of depressive and/or anxious symptoms was 18.5% in women and 7.4% in men. Age and previous IVF treatments seem not to be associated with incidence of depressive or anxious symptoms. Conclusion Both the prevalence and incidence of depressive and/or anxious symptoms in couples undergoing IVF treatment were worthy of note and should not be underestimated. More attention must be paid to psychological aspects in young women and in couples with a long history of infertility or previous failure treatments. Having an anxious partner was associated with anxious and depressive symptoms. For this reason, both males and females might benefit from psychological intervention, which could also help them to be supportive to each other.

Background A possible and neglected concern in women with endometriosis undergoing IVF is the potential risk of progression of the disease. We set up a prospective study mainly aimed at evaluating the impact of IVF on endometriosis-related symptoms. Materials and methods Women with surgical or echographic diagnosis of endometriosis and selected for IVF were included. In the month preceding the IVF attempt and at a second evaluation 3-6 months after the cycle, women who did not get pregnant underwent clinical assessment and transvaginal ultrasonography. Each patient was requested to complete a questionnaire on the presence, severity and modifications of endometriosis-related symptoms before and after the IVF cycle. Results Overall, 64 patients completed the study protocol. The Biberoglu-Behrman Scores and the Verbal Rate Scales for dysmenorrhea, dispareunia and chronic pelvic pain did not worsen after the procedure. Other endometriosis-related symptoms also did not change. There was no modification in size and number of endometriomas and deep peritoneal nodules. The number (%) of women reporting general improvement and worsening were 14 (22%) and 7 (11%), respectively. Conclusions IVF does not expose women to a consistent risk of endometriosis-related symptoms progression.

In oral rehabilitation with dental implants, severely resorbed alveolar ridges are a challenging problem due to the reduced height of the residual bone. Continuous search for minimally invasive procedures has resulted in the conception of reduced-length dental implants, decreasing the necessary amount of bone for implantation, thereby reducing the need of bone-grafts. Given the growing demand in the field of implant dentistry and the continuous development of surgical techniques, this study aimed to review the current literature on the predictability and success rate of short implants. Relevant articles published in the PubMed database between the years of 2004 and 2014 were selected using the following key-words: short dental implants, extra-short implants, survival rate, implant, mandible, maxilla, prognosis, implant survival, implant length. Based on the literature review, we concluded that short implants showed high predictability and high success rate in the short term, therefore they are one of the current options for the rehabilitation of atrophic alveolar ridges. Further longitudinal studies are necessary to define more reliably parameters for their proper use, ensuring the achievement of high success rates and survival rates with the use of this type of implant.o assess the attitude and practice of dental professionals towards using of advance radiographic technique.

Background: Major vascular injuries (MVI) still occur in laparoscopic surgery. Methods: We report our institution's experience of two MVI (aortic lesions) in a series of 3545 laparoscopies (July 1991–December 2000). We compared this experience with other series reporting MVI from Medline, Embase, Current Contents, and Best Evidence. Results: There were no deaths, but we had 23 postoperative and eight intraoperative bleedings, including two hepatic vessel lesions during dissection and six vascular lesions (four minor vessels and two aortic) related to trocar insertion. Prevention and treatment options are also discussed. Conclusions: The incidence of MVI reported in the literature is 0.05%, but the true incidence is difficult to estimate because results are not always comparable and there is a possibility of underreporting. The mortality rates (8–17%) are high. No technique or instrumentation is completely safe; therefore, a high level of alertness must be maintained at all times and precautions must be adopted to avoid major complications.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive disease leading to worsening functional status and reduced survival for those patients who cannot undergo pulmonary endarterectomy (PEA). Pharmacotherapy with novel drugs for pulmonary hypertension may be useful in treating patients who are poor candidates for surgery, but there are still few clinical data on medical therapy for CTEPH. The aim of this prospective open-label, multicenter, study is to compare the efficacy of 1-year bosentan treatment to standard drugs in nonoperated patients with CTEPH.Thirty-four nonoperated patients with CTEPH were enrolled. Functional assessment included 6 minute walk test (6MWT), Borg index, WHO classification, arterial blood gases and echocardiography systolic pulmonary artery pressure (sPAP). Seventeen patients received bosentan (62.5 mg b.i.d. for 4 weeks and then 125 mg b.i.d.); 17 patients were treated with standard therapy alone.At admission sPAP was 76.18+/-5.96 mmHg in bosentan group and 71.48+/-3.71 mmHg in controls, p(a)O(2) 64.68+/-2.25 mmHg in bosentan group, and 59.52+/-2.05 mmHg in controls, 6MWT 297.53+/-34.25 mt in bosentan group, and 268.47+/-36.54 mt in controls. After 12 months there were significant differences between the groups in the 6MWT (+57.24+/-22.21 m vs -73.13+/-21.23 m, p0.001), dyspnoea index (Borg score 4.29+/-0.49 vs 7.06+/-0.32, p0.001) and oxygenation (p(a)O(2) 65.93+/-3.76 mmHg vs 48.48+/-1.31 mmHg, p0.001). The sPAP was stable after 12 months of bosentan (76.18+/-5.96 mmHg vs 71.00+/-5.41 mmHg, p=0.221) in contrast to controls (71.48+/-3.71 mmHg vs 80.44+/-4.70 mmHg, p=0.029).The data of this open-label study in nonoperated CTEPH patients suggest an improvement in functional outcomes adding Bosentan to diuretics and oral anticoagulants. No improvement was observed using only standard drugs after 1-year.

To evaluate the influence of IVF on the dimension of leiomyomas, we selected 72 women with small intramural or subserosal leiomyomas and assessed the size of these lesions before and after the treatment cycle. The mean ± SD diameters of the tumors at these two time points were 20.5 ± 9.5 and 20.6 ± 10.2 mm, respectively, thus supporting the conclusion that IVF does not influence the growth of these lesions.

In 2010 a Cochrane review confirmed that folic acid (FA) supplementation prevents the first- and second-time occurrence of neural tube defects (NTDs). At present some evidence from observational studies supports the hypothesis that FA supplementation can reduce the risk of all congenital malformations (CMs) or the risk of a specific and selected group of them, namely cardiac defects and oral clefts. Furthermore, the effects on the prevention of prematurity, foetal growth retardation and pre-eclampsia are unclear. Although the most common recommendation is to take 0.4 mg/day, the problem of the most appropriate dose of FA is still open. The aim of this project is to assess the effect a higher dose of peri-conceptional FA supplementation on reducing the occurrence of all CMs. Other aims include the promotion of pre-conceptional counselling, comparing rates of selected CMs, miscarriage, pre-eclampsia, preterm birth, small for gestational age, abruptio placentae. This project is a joint effort by research groups in Italy and the Netherlands. Women of childbearing age, who intend to become pregnant within 12 months are eligible for the studies. Women are randomly assigned to receive 4 mg of FA (treatment in study) or 0.4 mg of FA (referent treatment) daily. Information on pregnancy outcomes are derived from women-and-physician information. We foresee to analyze the data considering all the adverse outcomes of pregnancy taken together in a global end point (e.g.: CMs, miscarriage, pre-eclampsia, preterm birth, small for gestational age). A total of about 1,000 pregnancies need to be evaluated to detect an absolute reduction of the frequency of 8%. Since the sample size needed for studying outcomes separately is large, this project also promotes an international prospective meta-analysis. The rationale of these randomized clinical trials (RCTs) is the hypothesis that a higher intake of FA is related to a higher risk reduction of NTDs, other CMs and other adverse pregnancy outcomes. Our hope is that these trials will act as catalysers, and lead to other large RCTs studying the effects of this supplementation on CMs and other infant and maternal outcomes. Italian trial: ClinicalTrials.gov Identifier: NCT01244347 . Dutch trial: Dutch Trial Register ID: NTR3161 .

The role of non-invasive nocturnal domiciliary ventilation (NNV) in chronic obstructive pulmonary disease (COPD) patients with chronic hypercapnia is still discussed. The aims of this study were to evaluate the long-term survival, the clinical effectiveness and side-effects of NNV in these patients. Forty-nine stable hypercapnic COPD patients on long-term oxygen therapy (LTOT) were assigned to two groups: in Group 1, 28 patients performed NNV by pressure support modality in addition to LTOT; in Group 2, 21 patients continued their usual LTOT regimen. Treatment was assigned according to the compliance to NNV, after an in hospital period. Mortality rate, hospital stay (HS) and ICU admissions (IA) were recorded in the two groups. HS and IA were compared to those recorded in a similar period of follow-back. Lung and respiratory muscle function, dyspnoea, and exercise capacity (by 6-min walk test) were evaluated baseline and every 3-6 months up to 3 yr. Mean follow-up time was 35 +/- 7 months. Mortality rate was not different between the two groups: 16, 33, 46% and 13, 28, 50% at 1, 2 and 3 yr in Groups 1 and 2 respectively. Lung and respiratory muscle function did not significantly change over time. A significant increase in 6-min walk test (from 245 +/- 78 to 250 +/- 88, 291 +/- 75, 284 +/- 89 m after 1, 2 and 3 yr respectively, P < 0.01) was observed only in patients undergoing NNV. In comparison to the follow back HS significantly decreased in both groups (from 37 +/- 29 to 15 +/- 12 and from 32 +/- 18 to 17 +/- 11 days/pt/yr in Groups 1 and 2 respectively, P < 0.001) whereas IA significantly decreased only in patients performing also NNV (from 1.0 +/- 0.7 to 0.2 +/- 0.3/pt/yr, P < 0.0001). Addition of NNV by pressure support modality to LTOT does not improve long term survival but significantly reduces ICU admissions and improves exercise capacity in severe COPD with hypercapnia.

A description of the double solenoid system (RIBRAS) operating since 2004 in one of the beam lines of the Pelletron Laboratory of the Institute of Physics of the University of Sao Paulo is presented. The recent installation of the secondary scattering chamber after the second solenoid is reported and the first experiment in RIBRAS using both solenoids is described.

BACKGROUND There is a growing consensus that ovarian endometriomas should not be systematically removed in women selected for IVF. However, some recent evidence suggested that the presence of these cysts may negatively affect the course of pregnancy. METHODS We set up a multicenter retrospective cohort study, including two infertility units. We analyzed data from patients achieving singleton clinical pregnancies through IVF comparing the pregnancy outcome between 78 pregnant women with endometriomas at the time of IVF and 156 patients who achieved pregnancy through IVF without endometriomas. RESULTS The number of live births in women with and without endometriomas were 61 (78%) and 130 (83%), respectively (P = 0.39). The adjusted odds ratio (OR) of live birth in affected cases was 0.79 [95% confidence interval (CI): 0.38-1.68]. No differences were observed in late pregnancy and neonatal outcomes between the two groups. In particular, the rate of preterm birth and small-for-gestational age (SGA) was similar. The adjusted ORs were 0.47 (95% CI: 0.14-1.54) and 0.56 (95% CI: 0.12-2.56), respectively. CONCLUSIONS Women with endometriomas achieving pregnancy through IVF do not seem to be exposed to a significant increased risk of obstetrical complications.

Scientific evidence for the therapeutic benefits of long-term oxygen therapy (LTOT) in patients with hypoxemia due to chronic obstructive pulmonary disease (COPD) is based on two landmark prospective randomized clinical studies published about thirty years ago [1–2].

background: The impact of fibroids, not encroaching the endometrial cavity, have on the rate of success of IVF is still controversial. Recent meta-analyses suggest a detrimental effect of intramural lesions but not subserosal lesions. However, they also emphasize the need for further evidence. In order to elucidate this, we designed a prospective cohort study to compare the rate of success of IVF in women with and without fibroids. methods: Exposed women were those with asymptomatic intramural or subserosal fibroids with a diameter below 50 mm and who were selected for IVF. Unexposed women were those free of fibroids, who were matched to cases by age and number of previous IVF cycles. All recruited patients underwent hystero-sonography to rule out intra-cavitary lesions. results: There were 119 cases and 119 controls recruited. The number of clinical pregnancies in women with and without fibroids was 28 (24%) and 22 (19%), respectively (P ¼ 0.43). The adjusted odds ratio (OR) for pregnancy in affected women was 1.38 [95% confidence interval (CI): 0.73 –2.60]. The number of deliveries was 22 (18%) and 16 (13%), respectively (P ¼ 0.38). The adjusted OR was 1.45 (95% CI: 0.71 –2.94). Similar results emerged when focusing exclusively on women carrying intramural lesions (n ¼ 80 couples). There was no significant relationship between clinical outcome and either the number or size of the fibroids. conclusions: In asymptomatic patients selected for IVF, small fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure.

Background/Aims: Limited information is available regarding the quantity of blood loss associated with uncomplicated transvaginal oocyte retrieval. The aim of the present study was evaluating the quantity of such a loss. Methods: One hundred and fifty consecutive women undergoing oocyte retrieval were recruited. They underwent blood test assessment and ultrasonographic transvaginal evaluation at three different times: (1) immediately before initiating oocyte retrieval, (2) 4–6 h later, and (3) 72 h later. Results: At 4–6 h after oocyte retrieval, the red blood cell count and the hemoglobin concentration were significantly reduced, whereas pelvic free fluid had significantly increased. The estimated median (Interquartile range) blood loss was 72 (–8/162) ml. None of the recruited women was found to have a hemoglobin reduction >2 g/day or an increase in the pelvic free fluid >200 ml or a calculated blood loss >500 ml (0.0%, 95% CI: 0.0–2.4%). No significant worsening from baseline was observed at the 72 h evaluation. Conclusions: The quantity of blood loss following oocyte retrieval is clinically unremarkable in the vast majority of women.

Nias is an island located approximately 112 km off the west coast of Sumatra. As Feldman remarks, this island 'has been the subject of a great deal of literature' (1977:5); sources (reports written largely by travellers, Dutch colonial officials, and German Lutheran missionaries) include many monographs and hundreds of articles covering a wide range of topics. The most important sources are Chatelin 1881, Thomas 1892 and Sunder mann 1905 on religion, and Schr?der 1917 on history and ethnograhpy, while Modigliani's book (1890) is also quite interesting. Several works focused on Nias architecture are de Boer 1920, Feldman 1977, 1979, and 1984, and Viaro 1980. Information about Central Nias is available in Hammerle 1982 and 1984, and about South Nias in De Vet 1964, La'ija 1975, Marschall 1976, and Scarduelli 1982, 1985, 1986a, 1986b, and 1987. Extensive bibliographies on Nias are to be found in Suzuki 1958, Feldman 1977, Roth 1985, Scarduelli 1986a. In spite of the impressive number of old texts available on the ethno graphy of Nias, the descriptions which they include are often inaccurate and defective and, what is more, present a mix of data from different parts of the island, although the linguistic and cultural differences are consider able. Indeed, different dialects are spoken in North, Central and South Nias; there are also differences in the lay-out of villages, the structure of houses, political organization and rituals. The available literature as Feldman ( 1977:6) points out 'very often presents a picture of Nias culture as a single unified system', while the ethnographic information derives from the north, where missions and administrative centres were located. The result is that only a very small proportion of the facts presented in the sources concerns the southern districts. Consequently, as the present ar ticle deals with South Nias, I had to base my findings exclusively on the data which I myself collected during fieldwork in Nias in 1979, 1982 and 1985.

Central venous catheters (CVCs) are widely used for therapeutic purposes and to measure hemodynamic variables that cannot be recorded from a peripheral vein. However, the method can involve complications. In cardiac surgery, CVCs are electively placed in the right internal jugular vein but there is little information on deep venous thrombosis (DVT) in catheterized veins (CVC-related DVT) or on secondary pulmonary embolism (PE). The impact of CVC-related DVT and PE in cardiac surgery and measures to prevent PE were assessed. We used ultrasonography (US) to check the point of insertion of CVC in 815 patients in the intensive cardiac rehabilitation unit after heart surgery. In this series, 386 patients (48%) had CVC-related DVT; those already receiving anticoagulant, and considered at low risk, continued that therapy, while those taking an antiplatelet agent (aspirin 100 mg daily) but deemed at high risk of PE from the US findings were given an anticoagulant instead. Only patients with CVC-related DVT at low risk of PE continued taking aspirin. At 3 months, there were no cases of PE among patients receiving an anticoagulant, but six on antiplatelet had non-fatal PE. The prevalence of PE in the whole series of 815 patients was 0.7%. CVC-related DVT is a frequent complication of heart surgery. Anticoagulant therapy started early does not prevent thrombus formation but probably prevents PE, whereas antiplatelet gives no such protection. Sonographic screening of the CVC removal in intensive care unit may be useful for avoiding PE after CVC-related DVT.

Objective The rationale of the clomiphene citrate challenge test (CCCT) is that day 10 serum FSH is influenced by the quality of the recruited oocytes. Biological evidence supporting this assumption is, however, lacking. The aim of this study is to investigate the relationship between results from the CCCT and the quantity and the quality of the recruited oocytes. Study design Patients selected for in vitro fertilization (IVF) and who were found to have elevated basal FSH (n = 114) underwent an IVF cycle using follicles developing during CCCT. Subsequently, a subgroup of patients (n = 89) underwent a second cycle receiving high doses of gonadotropins. The main outcome considered was the transfer of viable embryos. Results During the CCCT cycle, the area under the receiver operating characteristics (ROC) curves for day 3 and day 10 serum FSH to predict embryo-transfer was 0.48 (95% CI, 0.37–0.60) and 0.74 (95% CI, 0.63–0.82), respectively. In the subsequent cycle, the area under the ROC curves for the two variables was 0.58 (0.43–0.72) and 0.58 (0.43–0.72), respectively. Conclusions CCCT effectively mirrors the quantity and the quality of the recruited oocytes but its predictive value is low.

1. Background We developed this surgical protocol about performing intraoperative laparoscopy for staging in every patient affected by stomach cancer. Sensitivity and specificity of intraoperative laparoscopy are compared with conventional preoperative staging techniques.2. Methods From January 1994 to June 1999, 83 patients affected by stomach cancer were accepted in our department: 12 patients (14.5%) were excluded from our study after the preoperative staging; in 71 patients (85.5%) an explorative laparoscopy as the first step of the operation was performed.3. Results Laparoscopy confirmed preoperative staging in 53 cases (74.6%), in 12 patients demonstrated an overstaging. Laparoscopy demonstrated in 6 patients unsuspected causes of unresectability.4. Conclusions When performed in patients affected by malignant neoplasm and declared resectable, intraoperative laparoscopy can demonstrate conditions not detectable by traditional preoperative investigations, consequently reducing to zero explorative laparotomies.

BACKGROUND Oesophageal leiomyomas are usually so easily removed that thoracotomy seems out of proportion and thoracoscopic removal is therefore highly desirable. METHODS Out of a total of 1003 thoracoscopic operations undertaken between July 1991 and December 1996, seven patients underwent thoracoscopic removal of oesophageal leiomyoma. All of them had been preoperatively studied by oesophagogastroscopy and computed tomographic scanning of the chest which had confirmed the presence of a lesion with benign features. The surgical technique required intubation with a double lumen tube. Operative access was gained through the right chest via three ports and a small utility thoracotomy in the inframammary sulcus. The mean operating time was 120 minutes. RESULTS Conversion to open thoracotomy was necessary in one case with a very large horseshoe-shaped leiomyoma which was firmly adherent. The mean postoperative hospital stay was seven days. No intraoperative deaths or postoperative complications occurred. CONCLUSIONS The simplicity and safety of the thoracoscopic approach, combined with reduced surgical trauma and postoperative pain and functional and cosmetic advantages, make this technique the approach of choice for the removal of oesophageal leiomyomas.

One hundred ninety-one hyperprolactinemic patients (178 women and 13 men; 54 with pituitary macroadenoma, 53 with microadenoma, and 84 with idiopathic disease) were treated for 2 to 48 months with one or two of the following prolactin (PRL)-lowering drugs: bromocriptine, metergoline, and lisuride. All of the three drugs used were highly effective in lowering PRL levels and restoring gonadal function both in females and in males in the majority of patients with either idiopathic or tumorous disease. In poorly responsive patients, increasing the drug doses resulted in further PRL lowering for all the three drugs. Mild side effects were frequently encountered with initiation of drug treatment but spontaneously subsided in most cases; severe side effects, necessitating stopping of the treatment, occurred in only 12 instances, but changing of the drug allowed PRL-lowering treatment to be continued in 11 of them.

29 pregnancies occurred spontaneously in 28 women with mild to moderate hyperprolactinemia (prolactin levels up to 100 ng/ml). Only 4 of them showed tomographic evidence of microprolactinoma; 1 of the prolactinoma patients experienced a visual field defect at week 30, which was quickly controlled by bromocriptine treatment. Pregnancy was uneventful in the rest of the patients. Subjects who wished to lactate successfully breast-fed their babies. Of 22 women in whom prolactin levels were reevaluated at least 1 month after delivery and/or lactation, normal values were found in 9.

To investigate the effect of dopaminergic stimulation on gonadotrophin release, serum LH and FSH concentrations were measured during dopamine infusion (5 μg/kg/min for 120 min) in 8 healthy women in the early follicular phase, in 12 patients with hyperprolactinaemic amenorrhoea, in 5 subjects with premature ovarian failure and in 8 with polycystic ovarian disease and raised serum LH levels. Dopamine infusion produced a significant LH decrease compared with a control study using saline in all groups; there were no significant changes in FSH concentration. Between groups analysis showed a significantly greater LH fall in patients with polycystic ovarian disease than in the other groups. Dopamine inhibits LH release in healthy women and patients with anovulatory states of varying aetiology, and enhanced sensitivity to this inhibitory mechanism exists in polycystic ovarian disease. This finding suggests reduced dopamine activity at the median eminence level in this condition.

The PRL response to the dopamine antagonists sulpiride (100 mg i.m.) or domperidone (2 or 8 mg i.v.) was evaluated in healthy controls and in 148 patients with different hyperprolactinemic disorders (50 with idiopathic hyperprolactinemia, 58 with microprolactinoma, 19 with macroprolactinoma, 2 with empty sella, 8 with acromegaly, 7 with organic lesions of the hypothalamus, and 4 with idiopathic hypopituitarism of presumed hypothalamic origin). Mean PRL response to both drugs was significantly lower in all groups of patients than in controls, and significantly higher in subjects with idiopathic hyperprolactinemia than in those with pituitary adenomas or hypothalamic disease. Absent or impaired PRL responses were found in 38 % of idiopathic patients, in 91.5 % of microprolactinomas and in all of the patients with either macroprolactinoma, acromegaly, or hypothalamic disorders. Since the PRL response to dopamine antagonists depends on the presence of an endogenous dopaminergic tone, it is suggested that these figures reflect the incidence of major dopamine deficiency at pituitary lactotrophs in different hyperprolactinemic states. These data suggest that the pathophysiology of hyperprolactinemia in many patients with idiopathic disease is different from that of microprolactinoma. However, the finding of a normal PRL response to sulpiride in some subjects with radiologically or surgically proven microprolactinoma indicates that this test has no diagnostic value in the individual case.

All IVF programs have a consistent rate of failure in inducing ovulations. Pharmacological induction of ovulation is otherwise crucial for an IVF program because of the need for more than one ovum. Since it is well known that the best candidates for HMG treatment are hypogonadotropic women a short reversible hypogonadotropic state was induced in IVF patients by LH-RH agonist (Buserelin). Superovulation was then achieved with very high initial doses of FSH (Metrodin) in order to maximize the ovarian response. This technique used in 116 IVF women induced a satisfactory follicle growth even in 70% of the patients already poorly responsive to HMG stimulation.

SummaryDihydroergocristine. 20–40 mg/day, reduced serum prolactin to normal in h out of 40 hyperprolactinaemic women and by 50 per cent in a further 7 women. Menstruation was restored in 19 out of 29 of the women with amenorrhoea. and ovulation occurred in 21 of the 40 patients. When given to puerperal women, 20 mg/ day for 10 days. dihydroergocristine prevented lactation without untoward side effects.Dopaminergic drugs have become the standard treatment for hyperprolactinaemic disorders and also for the prevention of puerperal lactation (Thor-ner et al., 1980).Bromocriptine and other potent dopaminergic drugs, though very effective, are occasionally not tolerated by individual patients, and the need for alternative drugs has arisen. Dihydroergocristine, a well tolerated vasoactive drug which has been used for many years in the treatment of vascular disorders, has recently been shown to possess a prolac-tin lowering effect in acute studies (Ferrari el al., 1983).The present work was to investigate the pos...

Multiple ovulation was induced in 122 hypogonadotrophic IVF patients with large doses of HMG. The hypogonadotrophic state, short and reversible, was obtained by nasal administration of a GnRH agonist (200 micrograms, five times per day). In the 97 induced cycles, a mean of 9.1 follicles was recorded. A comparison of the results obtained for 36 patients who had already been treated with clomiphene and HMG showed both significantly more follicles per cycle (8.5 versus 3.0) and an increase in oocytes retrieved (6.7 versus 1.3) when treated with the agonist and HMG. In addition 11 of 18 already poorly responsive patients had normal responses. The luteal phase was supported by either HCG or progesterone injection. Plasma progesterone profiles were satisfactory and, as expected, the highest progesterone concentrations were associated with HCG treatment.

This paper reports the changes in prolactin levels after 12 spontaneous and 52 induced pregnancies in 54 women with unambiguous hyperprolactinaemia (median plasma prolactin levels 67.5 ng/ml, range 40-400). Twenty-three of the patients showed radiological evidence of prolactinoma. The pregnancies were induced in 37 patients by bromocriptine, in nine by metergoline, in two by lisuride and in four by other treatments. Of the 64 pregnancies, 16 ended in spontaneous abortion, while 48 went to term. Follow-up was continued for at least 6 months after delivery or until the end of lactation. In a control group of 32 hyperprolactinaemic women (median prolactin 70 ng/ml, range 40-400) not wishing to become pregnant, prolactin changes were similarly registered over a mean period of 15 months without any treatment (range 6-38 months). After pregnancy, a significant downward trend of plasma prolactin was observed in the puerperal women with a 'normalization' rate of 17%. No changes were observed in the 32 controls who did not become pregnant.

PRL secretory dynamics were evaluated by several stimulation and suppression tests in nine patients with hyperprolactinemia due to organic hypothalamic disease. Basal PRL levels ranged between 20-63 ng/ml. There was a normal PRL response to TRH in eight cases (i.e. doubling of basal levels), whereas none of the seven tested subjects responded to sulpiride. The same dissociation of responses was not observed in any of the patients who were still hyperprolactinemic after surgery. Concomitant dopamine infusion resulted in sulpiride-induced PRL release in the four subjects so studied. None of 50 other hyperprolactinemic patients (11 with macroprolactinoma, 18 with microprolactinoma, and 21 with idiopathic hyperprolactinemia) showed PRL response to TRH but not to sulpiride. The TRH-induced PRL increase was significantly higher than that induced by sulpiride in hypothalamic hyperprolactinemia and significantly lower in idiopathic disease as well as in healthy controls; no differences were found in prolactinoma patients. The administration of substances resulting in stimulation of pituitary dopamine receptors, such as dopamine and L-dopa, induced a normal PRL suppression in 7 patients with hypothalamic disease so tested, whereas central nervous system-acting dopaminergic drugs, such as carbidopa plus L-dopa and nomifensine, failed to lower PRL levels in most cases (even when normoprolactinemic after surgery). These data suggest that the mild to moderate hyperprolactinemia found in many patients with hypothalamic lesions is due to dopamine deficiency at the pituitary level, that TRH and dopamine receptors at the lactotropes are intact in this condition, and that paired TRH and sulpiride tests may be of some diagnostic utility in hyperprolactinemic patients. They further suggest that subjects with so-called idiopathic hyperprolactinemia do not suffer from the type of hypothalamic derangement exhibited by patients with organic lesions of the hypothalamus.