Search

Study question Are the annotations produced by AI comparable to manual annotations? Does AI accurately assess fertilisation checks, and predict embryo usage and blastulation compared to embryologists? Summary answer Automatic annotations by AI was consistent with manual annotations. AI implantation algorithms had strong prediction of blastulation and embryo usage. What is known already Currently, embryos are manually annotated for specific morphokinetic features during embryo development. This is a labour-intensive process, and dependent on training and experience, leading to inter and intra clinic variation. The decision to transfer, freeze or discard embryos relies heavily on these annotations. It is paramount that we develop a tool that will provide consistency and accuracy in annotation and produce scores that can facilitate decisions around embryo usage. AI has demonstrated its potential to achieve this, but first must be validated before its integration into clinical practice. There have been no such studies demonstrating this so far. Study design, size, duration Retrospective cohort study, that took place between September to December 2021 at a private fertility clinic in Spain. To control for embryo variability, this study only included 179 time-lapse videos for embryos created from donor eggs. This was based on the understanding that donor eggs are more likely to produce better quality blastocysts and embryos and thus will give the most optimal conditions for annotation in a validation framework. Participants/materials, setting, methods The same time-lapse cultured embryos were annotated manually and automatically by CHLOE(Fairtility, an AI-based tool). Manual and CHLOE annotations were compared to assess the strength of agreement (i) using intra-class correlation (ICC), and (ii) the proportion of corrections required at the pronuclei (PN) stage. AI accuracy in predicting blastulation at 30hours, and blastulation before 116 hours, was also assessed using AUC as the efficacy metric. Embryo usage was compared with the AI-generated ranking of embryos. Main results and the role of chance The majority of morphokinetic variables showed a very-strong agreement, with an ICC range of (0.81-1.00), namely for; tPNf, t2, t3, t5, t7, tSB, tB and tEB. Only t4 (0.5) showed a moderate agreement. On average (Mean+-Standard deviation), AI annotated t4 later than embryologists (36+-5vs39+-10 (hours)). All other variables fell within a strong ICC of (0.61-0.8). There were no very weak (0-0.2) or weak (0.21-0.4) variables. PN agreement between AI and embryologists was 93%: PN’s had to be corrected by an embryologist only 7%(n = 179) of the time. AI predicted blastulation on day 3 with a high level of sensitivity 0.77 and specificity 0.82, (AUC: 0.84,p Similarly, AI-generated ranking accurately correlated with embryologist decisions to freeze, transfer or discard embryos, with an overall high sensitivity 0.88 and specificity 0.67, (AUC: 0.84,p Limitations, reasons for caution This study only included embryos from donor eggs. Furthermore, this study occurred at a single site and is planned to be replicated at several clinics. Where there are discrepancies between human and AI, further studies are required to determine the ground truth. Wider implications of the findings This study demonstrates an AI framework to safely introduce AI in the fertility clinic. AI will accurately annotate embryos and give reliable scores to predict good quality blastulation, and inform decisions around embryo usage determination. AI provides a time-effective, objective tool in decision-making, with the potential to optimise success. Trial registration number not applicable

Study question Can lab-related variables (media type, oil viscosity, microdroplet volume and culture dish design) modulate media evaporation and improve its stability during culture? Summary answer Using dishes with pre-defined wells, big volume microdroplets and high-viscosity mineral oil can help to reduce media evaporation and improve osmolality stability during embryo culture. What is known already Osmolality measures the number of solute particles present in a solution and is an important variable of a human embryo culture system. High ambient temperature and low humidity may induce evaporation in culture media, increasing its osmolality. In addition, recent tendencies in IVF laboratories, such as extending the embryo culture uninterruptedly until day 6/7 or the use of dry benchtop incubators, may intensify evaporation. Surpassing a 300mOsm/kg threshold can result deleterious for embryo development and impair clinical results. Different strategies (e.g. oil type/volume, dish type, micro-drop volume) have been proposed to reduce evaporation and stabilize osmolality during culture. Study design, size, duration Four variables were analyzed in their capacity to reduce media evaporation: type of culture medium, micro-droplet volume, oil viscosity and type of culture dish. Dishes were prepared with 5ml of oil and 50µl microdroplets (25µl were used for the comparison of micro-droplet volumes). Dishes were cultured in parallel in a dry benchtop incubator (AD–3100, Astec), and osmolality measured daily for seven days with a freezing point depression osmometer (Osmo1®, Advanced Instruments, accuracy ≤2mOsm/kg). Participants/materials, setting, methods The following comparison groups were analyzed: 1) Seven commercial single-step media with three differing initial osmolalities (approximately 260, 280 and >290mOsm/kg); 2) oil with high, medium or low viscosity; 3) 50 vs. 25µl microdroplets; 4) 35mm flat Petri dish vs. 35mm dish with defined wells. Temperature in the incubator was monitored continuously (T+Button, BrightSentinel), as well as room temperature and humidity (Octax Log&Guard, Vitrolife). All were stable at 37.3±0.05oC, 22.1±0.6 oC and 67.4±7.4%, respectively. Main results and the role of chance Evaporation occurred in all the studied groups, but its rate was modulated by various parameters. Culture dishes designed with pre-defined wells reduced evaporation when compared to regular Petri dishes (Increase 11.3mOsm/kg and increase 12.5mOsm/kg, respectively from day 0 to 7 (P = 0.007)). Similarly, oil viscosity had an impact in osmolality stability during culture, with an increase of 14.7mOsm/kg, 16.3mOsm/kg and 19.2mOsm/kg observed when using mineral oil with high, medium and low viscosity, respectively (P = 0.009). Finally, reducing the volume of the medium microdroplets from 50 to 25µl derived in higher evaporation rates, but without significant differences (Increase 14.7mOsm/kg and increase 15.8mOsm/kg, respectively (P = 0.325)). Different evaporation rates were observed between the seven studied culture media attending their three-differing initial osmolalities. Significant differences were observed for a media respect another three media with differing initial osmolality (P = 0.001, P = 0.01 and P = 0.015). Their initial osmolality had a direct correlation with the maximum osmolality reached at the end of culture. Thus, media with a high initial osmolality (>290mOsm/kg) resulted in hyperosmotic media above the recommended 300mOsm/kg threshold by the end of culture and, by contrast, the studied media with lower initial values were able to maintain osmolality below 300mOsm/kg for the whole duration of the culture. Limitations, reasons for caution While a clear effect was observed by the studied variables, other parameters, such as oil volume or dish preparation techniques, could also play a role in osmolality maintenance and could be studied in the future. Additionally, these findings could vary between different centers and should be validated in each laboratory. Wider implications of the findings: Osmolality has been shown to have a direct impact on embryo development, embryo quality and clinical outcomes. Carefully defining the consumables and methodologies used in the IVF laboratory will improve the stability of the culture system and, consequently, reduce the stress imparted to the embryos and gametes under culture. Trial registration number Not applicable

Study question Should we consider embryo quality as one of the most important criteria to follow when transferring a mosaic embryo? Summary answer Embryo quality is an implantation biomarker both for euploid and mosaic embryos, and also a determinant for selecting the most eligible mosaic for transfer. What is known already Several studies show the benefit of transferring mosaic embryos when there are no euploid embryos to transfer, and they still result in ongoing pregnancies and what is more important is that they result in healthy babies. Studies and guidelines suggest prioritizing mosaic embryos based on maternal age, chromosomes impacted, percentage of aneuploidy, number of chromosomes involved, type of mosaic (simple vs complex, segmental vs complete, monosomy vs trisomy) but embryo quality is never part of these criteria. Studies claim that mosaic implantation rate is lower than euploid embryos, but they never show if both populations are comparable in terms of quality. Study design, size, duration This is a retrospective observational study performed in a private centre between February 2018 and January 2020. The study includes the data analysis of 96 euploid blastocysts and 14 low risk mosaic blastocysts (defining low risk regarding chromosome syndromes and less than 50% level mosaicism). All transferred in single embryo transfer (SET) to 105 patients after PGT-A (mean maternal age 38,9 years). The SET factor enables us to track the implantation outcome of all embryos. Participants/materials, setting, methods PGT-A with NGS technology was offered to patients of advanced maternal age and/or with repeated IVF failures. Trophectoderm biopsies were performed on day 5 and/or day 6 embryos, with laser assistance. Blastocyst morphology was scored in 3 groups: A: excellent (AA, AB, BA), B: good (BB), C: average and poor-quality embryos (BC, CB, CC). (Gardner-Schoolcraft classification) Low risk mosaic embryo transfer was offered to patients with no euploid embryos to transfer. Main results and the role of chance We found no significant differences between both populations (euploid and mosaic embryos) in terms of embryo quality (Chi^2 p-value =0,0975) so we were able to compare the overall implantation of similar quality populations. Despite euploid implantation being higher as described in most studies, no statistical differences (Chi^2 p-value = 0,4344) were found in terms of implantation rates between mosaic (57,0%) and euploid (67,6%) blastocysts during the same period. There are no differences between the mean age of both groups (39,7 vs 38,8 years, respectively). The implantation rates for euploid blastocysts were 79,5% (n = 39), 62,7% (n = 51) and 33,3% (n = 6) in the A, B and C blastocyst quality groups, respectively, showing significative differences among the three groups. The implantation rates of low-risk mosaic blastocysts were 100% (n = 3), 62,5% (n = 8) and 0,0% (n = 3) in the A, B and C blastocyst morphology groups, respectively, showing also still significant differences among the three groups despite the small population. (Chi^2 p-values according to implantation: Euploid =0,0434; Mosaic=0,0419) We have also compared the three quality categories between both populations showing no significative differences (Chi^2 p-values according to quality: A = 0,4344; B = 0,9894; C = 0,2568), concluding that same quality embryos behave the same way despite being euploid or mosaic. Limitations, reasons for caution The study is limited by its retrospective nature and the low number of mosaic embryos transferred as they are the last option for transfer. Additionally, it is common to transfer more than one mosaic embryo to increase the chances of pregnancy, therefore losing implantation track. Wider implications of the findings: Embryo quality has always been a strong biomarker predictable for implantation and this is also true for mosaic embryos as well. It is a simple concept, but we cannot compare implantation potential of euploid embryos with mosaic embryos without describing both populations in terms of quality. Trial registration number Not applicable

The fig 'Roxo de Valinhos' are currently cooled in a cold room at a temperature between 1 to 3°C, and it is unknown how long it takes to cool the fruits to that temperature. This work was based on the need to determine the parameters of forced air precooling of the fig 'Roxo de Valinhos' packed in wooden box used in the commercialization in the CEASA/Campinas-SP. The fruits were harvested at the rami stage (3/4 of maturity) and size type 8 corresponding to 8 fruits per box, making up a total of 24 fruits per package. The wooden box refers to a box without cover with external dimensions: length 39 cm, width 29 cm and height 10 cm and opening area of 36 cm 2 . There were 48 packages utilized, 24 at each side to form the californian type tunnel. The air flow was of 2.8 L/s per kilogram of product, with an average air velocity of 1.5 m/s. The initial temperature of the fruits was of 19°C and the final temperature of 1°C, which is a suitable temperature for fig storage. The internal temperature of the fruits was measured with thermocouples of T type (AWG #24) and the evolution of the temperature was registered by a Linx acquisition data system (AQDADOS). Based in the experimental data, it was determined that the cooling curve and an exponential analytical model to predict the cooling time. The cooling time was of 100 minutes, the cooling coefficient of 0.0289 min -1 the Biot number of 1.0 and the convective heat transfer coefficient of 18.8 W/m 3 °C . .

A aplicação de técnicas de automação e controle em casas de vegetação teve início nos anos 50, com o controle da temperatura através de termostatos; desde então, as mudanças tecnológicas têm abarcado todos os aspectos que compõem o sistema, do projeto estrutural até aspectos relacionados à sustentabilidade. Dentre os parâmetros que devem ser controlados, a temperatura e umidade relativa do ar, a radiação solar, a concentração de CO2, a ventilação e a fertigação têm tido uma evolução significativa, dos quais se apresenta uma panorâmica através da revisão do estado da arte de trabalhos publicados nessas temáticas, nos últimos anos. Na atualidade, temas relacionados com a redução do impacto ao meio ambiente e a produção eficiente e com qualidade, estão levando as casas de vegetação ao caminho da Agricultura de Precisão.The application of techniques of automation and control in greenhouses began in the years 50, starting with the control of temperature through thermostats. Since then, technological changes have covered all aspects that make up the system, from constructional features up to aspects of sustainability. The control of parameters sulh as, temperature and relative humidity, solar radiation, the concentration of CO2, ventilation and fertigation, had significant development, from which it provides a review of published works about these themes in recent years. Currently, issues related to reducing the impact to the environment and efficient production and quality, are taking the greenhouses towards Precision Agriculture.

A refrigeração é um excelente método para o armazenamento prolongado de produtos frescos. O uso de contêineres na agricultura é uma tecnologia simples e de fácil utilização que permite a manutenção da qualidade de produtos frescos, como frutas e hortaliças e a diminuição das perdas pós-colheita. Neste trabalho foram desenvolvidos uma série de experimentos com um contêiner frigorífico submetido a dois regimes de operação: vazio e com produto. Foram avaliadas as seguintes variáveis: temperatura, velocidade e umidade relativa do ar, além da pressão do sistema de refrigeração. Foi determinado o tempo de meio resfriamento de alface tipo americano (Latuca sativa L.), submetido a uma temperatura de 1ºC. Nas superfícies que recebem maior radiação solar o desvio da temperatura é de 1,5 ± 1ºC, com respeito às paredes que recebem menor radiação. A velocidade do ar variou de 2,1; 1,7 e 0,3 m/s, nos três planos estudados. O tempo de meio resfriamento da carga de alface variou entre 530 min (» 8 h), e 1.080 min (» 18 h), dependendo da posição das cabeças de alface no interior do contêiner. A umidade relativa do ar foi de 81-86% ± 1% e de 90-91 ± 1%, para o contêiner vazio e com carga, respectivamente.Refrigeration is an excellent method for storing horticultural fresh products such as fruits and vegetables. The use of refrigerated containers is a simple and ready-to-use technology allowing better quality and decreasing postharvest losses. In this work some experiments were conducted with a refrigerated container in two operating conditions: with and without load. The following variables were evaluated: air temperature, air velocity, air relative humidity, and pressure of the refrigeration system. The lettuce (Latuca sativa L.) half-cooling time was also determined when this product was stored at 1ºC. It was observed that the container surfaces receiving more radiation presented temperature increases of 1,5 ± 1ºC in contrast to the surfaces that were less exposed. Air speed ranged from 2.1; 1.7 and 0.3 m/s for the three studied surfaces. The lettuce half-cooling time varied from 530 min and 1.080 min, depending on the position of the head of lettuce in the container. The relative humidity of the air was 81-86% ± 1% in the empty container and 90-91 ± 1%, for the loaded container.

Polycythemia rubra vera (PRV) is a rare haematological disorder that has a high risk of stroke, although the pathophysiological origin of the cerebral ischaemia in this disease is not well known. We report a case of a stroke patient with PRV in whom bilateral embolic signals were detected by transcranial Doppler (TCD). Cerebral computed tomography showed a cortical middle cerebral artery infarction, echocardiography was normal, duplex-scan showed moderate left carotid stenosis and digital angiography disclosed right siphon stenosis. TCD examinations in the acute phase repeatedly showed a great number of bilateral microembolic signals (MESs). Four months later magnetic resonance angiography showed no flow signal in the right siphon and a severe stenosis of the proximal right MCA. The detection of bilateral MESs in the absence of cardiac sources of embolism observed in this patient suggests that ischaemic cerebral events in PRV may have an embolic origin favoured by a prothrombotic state.

Resumen Un seleccionado grupo de pacientes afectos de procesos traumaticos, malformativos, degenerativos, infecciosos o tumorales del complejo cervical alto que provocan una inestabilidad de este segmento, precisaran para su tratamiento una fijacion interna. Sobre todo, en los casos con inestabilidad atloaxoidea la fijacion mediante el atornillado posterior interarticular Cl-C2 suplementado a una artrodesis interlaminar Cl-C2 debera considerarse como una opcion terapeutica adecuada. En nuestro servicio 6 pacientes han sido intervenidos mediante esta tecnica, en otros 5 mas la artrodesis interarticular se asocio a una fijacion occipitocervical. La etiologia que indico el tratamiento quirurgico fue pseudoartrosis de fracturas de la base de la odontoides en 3 casos, artritis reumatoide en 3, rotura del ligamento transverso del atlas en 2 y tumores de axis en 3. Todos los pacientes obtuvieron una triple fusion osea interarticular e interlaminar. No hemos constatado ninguna complicacion biomecanica, neurologica, infecciosa ni vascular. Nuestra limitada experiencia demuestra que esta tecnica debe considerarse con fuerza en el tratamiento quirurgico de algunos pacientes con inestabilidad del segmento cervical alto, en particular en el caso de reintervenciones tras el fracaso de otras tecnicas.

Resumen De los 111 casos de fracturas del axis atendidos en nuestro servicio desde 1988 a 1998, 58 presentaban fracturas de la apofisis odontoides. De estos, 51 pacientes fueron intervenidos quirurgicamente mediante la tecnica del atornillado anterior. En este grupo, hemos conseguido demostrar radiologicamente la existencia de una buena consolidacion osea en 48 pacientes (92.3%). De todos los casos, en 38 se demuestra una buena alineacion (73%) y en 14 (26.9%) algun grado de desalineacion de la consolidacion osea. Las edades del grupo fueron de los 13 anos de edad del mas joven, hasta los 86 del de mayor edad. Hemos observado en la serie gran disparidad de desplazamientos de la odontoides al ingreso en el hospital. Solo 15 pacientes (25.8%) no tenian fracturas desplazadas a su ingreso. Los restantes 43 casos presentaban diversos grados de desplazamientos anterior (27.5%) o posterior (46.5%). En diez casos se ha presentado algun tipo de complicacion (19.2%), Yno hemos observado mortalidad directa respecto al procedimiento. A partir de los resultados analizados de los casos, la mayoria con controles superiores a los tres anos del procedimiento, concluimos que ninguno de los factores que habitualmente se citan como determinantes en la decision de la eleccion de la tecnica quirurgica apropiada para el tratamiento de este tipo de fracturas (edad, direccion y grado de desplazamiento, fracturas asociadas, clasificacion de las fracturas, o estado neurologico) ha sido un obstaculo ni tecnico ni funcional para obtener una correcta consolidacion de la fractura. A partir de los datos obtenidos creemos que los unicos factores que contraindican el atornillado anterior en todos los casos de fracturas de la odontoides, son el trazo de la fractura y la ruptura del ligamento transverso del atlas. A nuestro entender no existen fracturas estables de la base de la odontoides. Unicamente la localizacion de la fractura ha condicionado la actitud terapeutica en nuestra serie. Consecuentemente se propone que la clasificacion de las fracturas de la apofisis odontoides se limite a las del apex y de la base. Las primeras pueden ser tratadas conservadoramente. Las segundas, siempre inestables, deben ser tratadas mediante su atornillado anterior como primera opcion terapeutica.

A qualidade pós colheita de laranjas in natura (Citrus sinensis (L.) Osbeck, 'Baianinha'), foi avaliada em termos de suas propriedades químicas e físicas, em maio de 1998. Foi aplicado um delineamento inteiramente casualizado, com duas repetições, submetendo os frutos a dois tratamentos: armazenamento a temperatura ambiente (21 ± 0,4°C e UR= 60 ± 1,0%), e em uma câmara frigorífica (1 ± 0,5°C e UR = 85 ± 2,5%). Após 15 dias de armazenamento, foi observada uma diferença altamente significativa (P=0,01), nos níveis de ácido ascórbico (diminuição de 20% e 8%, nas laranjas expostas a temperatura ambiente e nos frutos refrigerados, respectivamente). A acidez titulável teve uma diminuição de aproximadamente 14%, para os frutos mantidos à temperatura ambiente, e de 8% para os frutos refrigerados. Comprovou-se um aumento de 30% (frutos em condições ambientais) e de 18% (frutos refrigerados), na relação sólidos solúveis e acidez titulável. Os resultados apontam uma tendência à perda da qualidade nos frutos mantidos em condições ambientais, o que reafirma a necessidade do uso de refrigeração para a conservação pós-colheita de laranja in natura.The postharvest quality of fresh oranges (Citrus sinensis (L.) Osbeck, 'Baianinha') was evaluated in terms of chemical and physical properties, in May of 1998. An experiment was carried out in a completely randomized design, with two replications, submitting the fruits to two treatments: storage at ambient conditions (21 ± 0.4°C and RH = 60 ± 1.0%, and in cold room (1 ± 0,5°C and RH = 85 ± 2,5%). After 15 days of storage, a highly significant difference was observed (P=0,01) in the levels of ascorbic acid (decrease of 20% and 8%, at ambient condition and refrigerated fruits, respectively). Titratable acidity decrease approximately 14%, for fruits at ambient condition, and 8% for the refrigerated fruits. It was observed an increase of 30% (ambient condition) and 18% (refrigerated fruits), in the brix/titratable acidity ratio. The results demonstrated that there is a tendency of quality loss for fruits maintained at ambient condition. Therefore, the use of refrigeration is necessary for the maintenance of post harvest quality of fresh orange.

A qualidade pós colheita de laranjas in natura (Citrus sinensis (L.) Osbeck, 'Baianinha'), foi avaliada em termos de suas propriedades químicas e físicas, em maio de 1998. Foi aplicado um delineamento inteiramente casualizado, com duas repetições, submetendo os frutos a dois tratamentos: armazenamento a temperatura ambiente (21 ± 0,4°C e UR= 60 ± 1,0%), e em uma câmara frigorífica (1 ± 0,5°C e UR = 85 ± 2,5%). Após 15 dias de armazenamento, foi observada uma diferença altamente significativa (P=0,01), nos níveis de ácido ascórbico (diminuição de 20% e 8%, nas laranjas expostas a temperatura ambiente e nos frutos refrigerados, respectivamente). A acidez titulável teve uma diminuição de aproximadamente 14%, para os frutos mantidos à temperatura ambiente, e de 8% para os frutos refrigerados. Comprovou-se um aumento de 30% (frutos em condições ambientais) e de 18% (frutos refrigerados), na relação sólidos solúveis e acidez titulável. Os resultados apontam uma tendência à perda da qualidade nos frutos mantidos em condições ambientais, o que reafirma a necessidade do uso de refrigeração para a conservação pós-colheita de laranja in natura.

Systemic lymphoma with meningeal involvement is frequent and diagnosis is based on the clinical features, the study of the cerebrospinal fluid and evaluation by magnetic resonance imaging (MRI). Lymphoma with involvement of the orbitary region is more frequent in the optic nerve (ON) than of the eye itself.We report the case of a patient with diffuse non Hodgkin gastric lymphoma of the large B cell type, which coursed with amaurosis, exophthalmus and signs of tumorous meningeal involvement. The ophthalmologic study revealed a thrombosis in the central retinal vein. The MRI exploration only showed an infiltration of the ON with no pathological meningeal enhancement. ON involvement consisted in a peripheral enhancement of the sheath with obliteration of the subarachnoid space. This pattern accounts for the existence of an ischemic neuropathy by direct compression over the central retinal vein and artery. There are different anatomopathologic or ophthalmologic studies of neuropathy of the ON by lymphoma in the literature, but there is only one case of diagnosis by MRI.ON involvement can be the only radiological sign in cases of neoplastic tumours with meningeal involvement. The radiological pattern consists in a peripheral infiltration of the sheath of the ON.

The new techniques of magnetic resonance imaging have produced a important advance in the early diagnosis of acute ischemic stroke. The diffusion weighted imaging (DWI) has a high sensitivity and specificity in the acute ischemia.70 years old woman with previous history of hypertension and dyslipemia. The patient presented sudden vertigo with cervical neck pain and gaze problems. The physical exploration revealed right miosis, nistagmus, IX and X cranial nerve affection and ataxia. The clinical diagnosis was Wallenberg s syndrome and a medulla lateral infarction. However DWI was normal (10 hours). The neurological deficit was persistent and a repeated study disclosed a lateral infarction of the medulla.The sensitivity of DWI is reduced during the first 24 hours. There are false negative diagnosis mainly in small infarctions of posterior territory.

Objective: To investigate the frequency of middle cerebral artery (MCA) stenosis in a series of nonselected patients and the coexistence of microembolic signals with stenosis. Methods: MCA stenosis was sought by transcranial Doppler (TCD) in 387 patients admitted consecutively with acute ischemic cerebrovascular disease within the first 48 hours of the onset of symptoms and again at 6 months. TCD monitoring for microembolic signals was performed on all patients with MCA stenosis. Results: MCA stenoses were found in 29 patients (7%), although in only 20 patients (5%) was the stenosis symptomatic. Microembolic signals were detected in five of 14 symptomatic stenoses (36%) monitored at the acute phase, but none were found in the chronic phase or in asymptomatic stenosis. Despite one third of symptomatic patients having had a further source of emboli, microembolic signals were detected only distally to the MCA stenosis. In the symptomatic group, 25% of stenoses had completely disappeared 6 months after stroke. Microembolic signal detection at the acute phase was associated with the subsequent disappearance of the stenosis. Conclusions: The frequency of symptomatic MCA stenosis in acute ischemic stroke was 5% in the population studied. Many stenoses are transient, and microembolic signals are often detectable at the poststenotic segment in the acute phase. The origin of at least 25% of symptomatic acute MCA stenoses may be embolic rather than atherosclerotic.

To evaluate the efficacy of a multistep strategy for Helicobacter pylori (HP) eradication.151 patients, with peptic ulcer or chronic gastritis, infected by HP, treated (first-step) with omeprazole (20 mg/12 h), clarithromycin (500 mg/12 h) and amoxycillin (1 g/12 h) for a week (OCA) and second-step (first-step failures) with omeprazole (20 mg/12 h), metronidazole (500 mg/12 h), tetracyclin (500 mg/6 h) and bismuth (120 mg/6 h) for two weeks.Intention-to-treat analysis, eradication was achieved with OCA in 78.1% (CI 95%: 71.6-84.7) and OMTB in 90.3% (CI 95%: 74.2-98), with an cumulative eradication rate of 96.7% (CI 95%: 92.4-98.9).The efficacy of multistep strategy is high. Therapy with OMTB its a good option after failure with OCA.

Polycythemia rubra vera (PRV) is a rare haematological disorder that has a high risk of stroke, although the pathophysiological origin of the cerebral ischaemia in this disease is not well known. We report a case of a stroke patient with PRV in whom bilateral embolic signals were detected by transcranial Doppler (TCD). Cerebral computed tomography showed a cortical middle cerebral artery infarction, echocardiography was normal, duplex-scan showed moderate left carotid stenosis and digital angiography disclosed right siphon stenosis. TCD examinations in the acute phase repeatedly showed a great number of bilateral microembolic signals (MESs). Four months later magnetic resonance angiography showed no flow signal in the right siphon and a severe stenosis of the proximal right MCA. The detection of bilateral MESs in the absence of cardiac sources of embolism observed in this patient suggests that ischaemic cerebral events in PRV may have an embolic origin favoured by a prothrombotic state.

Some patients with primary hypothyroidism (HP) develop massive thyrotrope cell hyperplasia determining pituitary hyperplasia with suprasellar enlargement and pituitary dysfunction. Although TRH secretion undoubtedly has some influence, the intervention of other possible factors determining this hyperplasia and dysfunction has been little assessed.Two patients with primary hypothyroidism with a serum TSH1,000 mU/I were studied. By means of CT and MR a pituitary hyperplasia was ascertained in the two patients. The pituitary functional reserve was investigated by the serum response of TSH and prolactin to the administration of TRH (400 micrograms, i.v.), bromocriptine (BRC, 5 mg, oral route), somatostatine (ST, 50 micrograms/kg/min, i.v. perfusion), and gonadotropin releasing hormone (GnRH, 100 micrograms, i.v.).The TRH induced increment of TSH was 145% and 193%, respectively, compared with basal values. After the administration of BRC, TSH decreased to 57% and 84% of basal values, and PRL to 46% and 43%, respectively. TSH and PRL concentrations did not change after the administration of ST or GnRH. In both cases, hyperplasia and pituitary dysfunction returned to normality after substitutive therapy with levothyroxine.Basal hyperprolactinemia and TSH and PRL responses to BRC administration suggest that central dopaminergic activity is decreased or abolished in patients with HP and pituitary hyperplasia. The massive thryrotrope cell hyperplasia and hypothyroidism itself determine pituitary dysfunction, which reverts after therapy with levothyroxine, a fact which is scarcely documented in literature.

We report a case of a 66-year-old white woman with calcium pyrophosphate dihydrate (CPPD) crystal deposition disease. The patient related a 2-month history of swelling with tenderness over the left pre-auricular region. A CT scan suggested a synovial chondromatosis. Surgical removal was done and histologic study showed CPPD crystals. This disease rarely involves the temporomandibular joint (TMJ) and is not usually considered in the differential diagnosis. To our knowledge, only 14 cases have been reported in the literature.

An aberrant internal carotid artery in the middle ear is rare. We present a new case with a red mass behind the eardrum. The diagnosis must be established by radiology and angiography. The consequences of injury and surgical intervention are serious. The purpose of this paper is to review the literature on the subject of vascular anomalies of the middle ear and to discuss the diagnosis and management of this lesion.

Summary The case is reported of a 48-year-old man suffering from Brucella endocarditis on a double prosthesis. The successful medical and surgical treatment is described. So far as the authors know, this is the first report of Brucella endocarditis from a heart valve prosthesis.

Kidney biopsies from fourteen patients with the nephrotic syndrome were studied by light, immunofluorescence and electron microscopy. Morphologically, all cases showed moderate diffuse mesangial cell proliferation. In all cases, immunofluorescent microscopy demonstrated diffuse and generalized deposits of IgM as the sole or predominant immunoglobulin. Electron microscopic examination showed electron dense deposits localized in the mesangium in seven cases. One nephrotic patient experienced spontaneous remission and eight others were steroid responsive. Only one of the five steroid resistant patients treated with chlorambucil showed clinical remission. Five steroid responsive patients relapsed. At present, four patients are healthy, having not relapsed for the past two years. Although deposits of IgM may be related to the renal pathology in cases of the nephrotic syndrome, immunofluorescence findings do not seem to be sufficiently consistent or characteristic to justify a possible subclassification of the idiopathic nephrotic syndrome.