RESUMEN
OBJECTIVE: Maternal diabetes in pregnancy is associated with structural anomalies of the fetal heart, as well as hypertrophy and functional impairment. This systematic review and meta-analysis aimed to estimate the effect of maternal diabetes on fetal cardiac function as measured by prenatal echocardiography. METHODS: We performed a search of the EMBASE, PubMed and The Cochrane Library databases, from inception to 4 July 2019, for studies evaluating fetal cardiac function using echocardiography in pregnancies affected by diabetes compared with uncomplicated pregnancies. Outcome measures were cardiac hypertrophy and diastolic, systolic and overall cardiac function as assessed by various ultrasound parameters. The quality of the studies was assessed using the Newcastle-Ottawa Scale. Data on interventricular septal (IVS) thickness, myocardial performance index (MPI) and E/A ratio were pooled for the meta-analysis using random-effects models. For pregnancies with diabetes, results were reported overall and according to whether diabetes was pregestational (PDM) or gestational (GDM). Results were also stratified according to the trimester in which fetal cardiac assessment was performed. RESULTS: Thirty-nine studies were included, comprising data for 2276 controls and 1925 women with pregnancy affected by diabetes mellitus (DM). Of these, 1120 had GDM, 671 had PDM and in 134 cases diabetes type was not specified. Fetal cardiac hypertrophy was more prevalent in diabetic pregnancies than in non-diabetic controls in 21/26 studies, and impaired diastolic function was observed in diabetic pregnancies in 22/28 studies. The association between DM and systolic function was inconsistent, with 10/25 studies reporting no difference between cases and controls, although more recent studies measuring cardiac deformation, i.e. strain, did show decreased systolic function in diabetic pregnancies. Of the studies measuring overall fetal cardiac function, the majority (14/21) found significant impairment in diabetic pregnancies. Results were similar when stratified according to GDM or PDM. These effects were already present in the first trimester, but were most profound in the third trimester. Meta-analysis of studies performed in the third trimester showed, compared with controls, increased IVS thickness in both PDM (mean difference, 0.75 mm (95% CI, 0.56-0.94 mm)) and GDM (mean difference, 0.65 mm (95% CI, 0.39-0.91 mm)) pregnancies, decreased E/A ratio in PDM pregnancies (mean difference, -0.09 (95% CI, -0.15 to -0.03)), no difference in E/A ratio in GDM pregnancies (mean difference, -0.01 (95% CI, -0.02 to 0.01)) and no difference in MPI in either PDM (mean difference, 0.04 (95% CI, -0.01 to 0.09)) or GDM (mean difference, 0.03 (95% CI, -0.01 to 0.06)) pregnancies. CONCLUSIONS: The findings of this review show that maternal diabetes is associated with fetal cardiac hypertrophy, diastolic dysfunction and overall impaired myocardial performance on prenatal ultrasound, irrespective of whether diabetes is pregestational or gestational. Further studies are needed to demonstrate the relationship with long-term outcomes. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Diabetes Gestacional/fisiopatología , Ecocardiografía , Corazón Fetal/fisiopatología , Embarazo en Diabéticas/fisiopatología , Ultrasonografía Prenatal , Adulto , Diabetes Gestacional/diagnóstico por imagen , Femenino , Corazón Fetal/diagnóstico por imagen , Humanos , Embarazo , Trimestres del Embarazo , Embarazo en Diabéticas/diagnóstico por imagenRESUMEN
BACKGROUND: Patients with a chronic hepatitis B virus (HBV) infection or patients who have recovered from an HBV infection are at risk for HBV reactivation (HBVr), especially if they need treatment with chemotherapy. International guidelines recommend routine HBV screening for all patients starting with chemotherapy. This study evaluates the implementation of a routine HBV screening protocol. METHODS: A retrospective study was performed between January 2015 and October 2016 at the Medical Centre Slotervaart Amsterdam. All patients with a solid or hematological malignancy starting intravenous chemotherapy were included. In September 2015, a protocol for routine HBV screening was introduced. HBV screening results were evaluated before and after implementation of the screening protocol. RESULTS: In total, 184 patients were included, of which 129 patients were actually screened; 37 of the 70 (53%) patients were screened in the group before implementation of the protocol and 92 of the 114 (81%) after implementation. Before routine HBV screening, 8/37 (21.6%) patients tested anti-HBc positive; after introduction of routine screening, 13/92 (14.1%) patients tested anti-HBc positive. After implementation of the screening protocol, no HBVr occurred. CONCLUSION: Implementation of routine HBV screening in patients starting chemotherapy increases identification of the number of patients identified as at risk for HBVr and contributes to prevention of HBVr. A high prevalence of anti-HBc positive patients was found during routine HBV screening, indicating the importance of screening. Awareness and implementation of routine HBV screening, together with knowledge of existing guidelines is necessary to increase the HBV screening rate in patients treated with chemotherapy.
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Antineoplásicos/efectos adversos , Hepatitis B/diagnóstico , Hepatitis B/prevención & control , Tamizaje Masivo/métodos , Activación Viral/efectos de los fármacos , Anciano , Antineoplásicos/uso terapéutico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias/tratamiento farmacológicoRESUMEN
Identifying a hereditary colorectal cancer (CRC) syndrome or familial CRC (FCC) in a CRC patient may enable the patient and relatives to enroll in surveillance protocols. As these individuals are insufficiently recognized, we evaluated an online family history tool, consisting of a patient-administered family history questionnaire and an automated genetic referral recommendation, to facilitate the identification of patients with hereditary CRC or FCC. Between 2015 and 2016, all newly diagnosed CRC patients in five Dutch outpatient clinics, were included in a trial with a stepped-wedge design, when first visiting the clinic. Each hospital continued standard procedures for identifying patients at risk (control strategy) and then, after a predetermined period, switched to offering the family history tool to included patients (intervention strategy). After considering the tool-based recommendation, the health care provider could decide on and arrange the referral. Primary outcome was the relative number of CRC patients who received screening or surveillance recommendations for themselves or relatives because of hereditary CRC or FCC, provided by genetic counseling. The intervention effect was evaluated using a logit-linear model. With the tool, 46/489 (9.4%) patients received a screening or surveillance recommendation, compared to 35/292 (12.0%) in the control group. In the intention-to-treat-analysis, accounting for time trends and hospital effects, this difference was not statistically significant (p = 0.58). A family history tool does not necessarily assist in increasing the number of CRC patients and relatives enrolled in screening or surveillance recommendations for hereditary CRC or FCC. Other interventions should be considered.
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Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/genética , Detección Precoz del Cáncer/métodos , Predisposición Genética a la Enfermedad/genética , Encuestas y Cuestionarios , Adulto , Anciano , Femenino , Asesoramiento Genético/métodos , Humanos , Masculino , Anamnesis/métodos , Persona de Mediana Edad , Sistemas en LíneaRESUMEN
Chronic hepatitis C virus (HCV) infection is a major cause of chronic liver disease and liver-related death. Recently, multiple regimens of different direct-acting antiviral agents (DAAs) have been registered. Although treatment with sofosbuvir (SOF) and simeprevir (SMV) is registered for the treatment of genotype 4 patients in some countries, data on efficacy of this combination are lacking. We aimed to assess the efficacy of SOF and SMV with or without RBV during 12 weeks in a real-life cohort of genotype 4 HCV patients. A retrospective multicentre observational study was conducted in 4 hospitals in Amsterdam, the Netherlands, including patients with advanced liver fibrosis or liver cirrhosis treated with SOF plus SMV with or without RBV during 12 weeks for a genotype 4 chronic HCV infection from 1 January 2015 to 1 August 2015. Sustained viral response (SVR) was established at week 12 after end of treatment. A total of 53 patients with genotype 4 HCV infection, treatment naïve and experienced, were included. SVR was achieved in 49 of 53 patients (92%). The four failures all had a virological relapse and did not receive ribavirin. Three were nonresponder to earlier interferon-based treatment, and one was treatment naive. In this real-life cohort of patients with HCV genotype 4 infection and advanced liver fibrosis/cirrhosis, we show that treatment with SOF and SMV is effective. The addition of RBV could be considered in treatment-experienced patients as recommended in guidelines.
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Antivirales/uso terapéutico , Genotipo , Hepacivirus/genética , Hepatitis C Crónica/tratamiento farmacológico , Cirrosis Hepática/patología , Simeprevir/uso terapéutico , Sofosbuvir/uso terapéutico , Adulto , Anciano , Femenino , Hepacivirus/clasificación , Hepacivirus/aislamiento & purificación , Hepatitis C Crónica/complicaciones , Hepatitis C Crónica/virología , Humanos , Cirrosis Hepática/virología , Masculino , Persona de Mediana Edad , Países Bajos , Inhibidores de Proteasas , Recurrencia , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVES: To evaluate patient burden and preferences for MR colonography with a limited bowel preparation and automated carbon dioxide insufflation in comparison to conventional colonoscopy. METHODS: Symptomatic patients were consecutively recruited to undergo MR colonography with automated carbon dioxide insufflation and a limited bowel preparation followed within four weeks by colonoscopy with a standard bowel cleansing preparation. Four questionnaires regarding burden (on a five-point scale) and preferences (on a seven-point scale) were addressed after MR colonography and colonoscopy and five weeks after colonoscopy. RESULTS: Ninety-nine patients (47 men, 52 women; mean age 62.3, SD 8.7) were included. None of the patients experienced severe or extreme burden from the MR colonography bowel preparation compared to 31.5% of the patients for the colonoscopy bowel preparation. Colonoscopy was rated more burdensome (25.6% severe or extreme burden) compared to MR colonography (5.2% severe or extreme burden) (P<0.0001). When discarding the bowel preparations, the examinations were rated equally burdensome (P=0.35). The majority of patients (61.4%) preferred MR colonography compared to colonoscopy (29.5%) immediately after the examinations and five weeks later (57.0% versus 39.5%). CONCLUSION: MR colonography with a limited bowel preparation and automated carbon dioxide insufflation demonstrated less burden compared to colonoscopy. The majority of patients preferred MR colonography over colonoscopy.
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Dióxido de Carbono , Colonoscopía , Neoplasias Colorrectales/patología , Costo de Enfermedad , Insuflación/métodos , Espectroscopía de Resonancia Magnética , Prioridad del Paciente , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prioridad del Paciente/estadística & datos numéricos , Estudios Prospectivos , Encuestas y CuestionariosRESUMEN
BACKGROUND: Radiation-associated angiosarcoma (RAAS) of the breast is a rare, aggressive disease. The incidence is increasing with the prolonged survival of women irradiated for primary breast cancer. Surgery is the current treatment of choice. Prognosis is poor. This review aims to evaluate all publications on primary treatment of RAAS to identify prognostic factors and evaluate treatment modalities. METHODS: Databases were searched for articles with published individual patient data on prognostic factors, treatment and follow-up of patients with RAAS. A regression analysis was performed to test the prognostic values of age, interval between primary treatment and RAAS, tumour size and grade on the local recurrence-free interval (LRFI) and overall survival (OS). The effects of treatment modalities surgery, radiation (with or without hyperthermia) and chemotherapy or combinations were evaluated. RESULTS: 74 articles were included, representing data on 222 patients. In these patients, the 5-year OS was 43% and 5-year LRFI was 32%. Tumour size and age were significant prognostic factors on LRFI and OS. Of all patients, 68% received surgery alone, 17% surgery and reirradiation and 6% surgery with chemotherapy. The remaining 9% received primary treatments without surgery. Surgery with radiotherapy had a better 5-year LRFI of 57% compared to 34% for surgery alone (p=0.008). The value of other treatment modalities could not be assessed. CONCLUSIONS: This systematic review confirms the poor prognosis of RAAS. Tumour size and age were of prognostic value. The addition of reirradiation to surgery in the treatment of RAAS appears to enhance local control.
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Neoplasias de la Mama/radioterapia , Hemangiosarcoma/terapia , Neoplasias Inducidas por Radiación/terapia , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/diagnóstico , Neoplasias de la Mama/etiología , Neoplasias de la Mama/mortalidad , Neoplasias de la Mama/terapia , Supervivencia sin Enfermedad , Femenino , Hemangiosarcoma/diagnóstico , Hemangiosarcoma/etiología , Hemangiosarcoma/mortalidad , Humanos , Estimación de Kaplan-Meier , Persona de Mediana Edad , Análisis Multivariante , Clasificación del Tumor , Recurrencia Local de Neoplasia , Neoplasias Inducidas por Radiación/diagnóstico , Neoplasias Inducidas por Radiación/etiología , Neoplasias Inducidas por Radiación/mortalidad , Radioterapia/efectos adversos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Carga TumoralRESUMEN
OBJECTIVES: To evaluate the diagnostic performance of MR colonography using automated carbon dioxide (CO2) insufflation for colonic distension, with colonoscopy serving as the reference standard. METHODS: Ninety-eight symptomatic patients underwent MR colonography with faecal tagging and automated CO2 insufflation. Three readers (one expert (reader 1), and two less experienced (readers 2 and 3)) evaluated the images for the presence of colorectal lesions. Bowel distension was evaluated on a 4-point scale. Results were verified with colonoscopy and histopathological analysis. RESULTS: Per-patient sensitivity for lesions ≥10mm was 91.7% (11 of 12) (reader 1), 75.0% (9 of 12) (reader 2), and 75% (9 of 12) (reader 3). Specificity was 96.5% (82 of 85) (reader 1), 97.7% (83 of 85) (reader 2), 95.3% (81 of 85) (reader 3). Per-patient sensitivity for lesions ≥6mm was 85.7% (18 of 21) (reader 1), 57.1% (12 of 21) (reader 2), and 57.1% (12 of 21) (reader 3). Specificity was 86.8% (66 of 76), 98.7% (75 of 76), 90.8% (69 of 76), respectively. Per-patient sensitivity for advanced neoplasia of ≥10mm and ≥6mm was 88.9% (8 of 9) for all readers. Specificity for ≥10mm and ≥6mm was 98.9% (87 of 88) (reader 1), 97.7% (86 of 88) (reader 2), 96.6% (85 of 88) (reader 3). 94.4% of the colon segments were adequate to optimal distended with dual positioning. CONCLUSION: MR colonography can accurately detect lesions ≥10mm, and advanced neoplasia ≥6mm. Sufficient distension was achieved using automated CO2 insufflation for colonic distension in MR colonography.
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Dióxido de Carbono , Neoplasias Colorrectales/patología , Aumento de la Imagen/métodos , Interpretación de Imagen Asistida por Computador/métodos , Insuflación/métodos , Imagen por Resonancia Magnética/métodos , Adulto , Anciano , Anciano de 80 o más Años , Dióxido de Carbono/administración & dosificación , Colonoscopía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Método Simple CiegoRESUMEN
Amorphous microporous silica (AMS) xerogel materials were synthesized in an acid-catalyzed sol-gel process. The porosity of AMS was adapted by varying sol-gel synthesis parameters including the molar hydrolysis ratio (r-value), HCl:Si molar ratio, the type of silicon alkoxide source and the solvent. AMS particles of millimeter size were loaded with ibuprofen, by heat treatment and melt impregnation. In vitro release experiments were performed in simulated gastric and intestinal fluid. The release kinetics were critically depending on the AMS particle size distribution and the micropore diameter. The release was interpreted as configurational diffusion in the AMS micropores. The stability of unloaded and ibuprofen loaded AMS material upon storage was investigated using nitrogen physisorption, DSC analysis and in vitro release experiments. Ibuprofen loaded AMS formulations show remarkable stability, which can be attributed to the presence of ibuprofen molecules in the channels, functioning as scaffolds to support the pore structure.
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Preparaciones de Acción Retardada , Ibuprofeno/administración & dosificación , Dióxido de Silicio , Fenómenos Químicos , Portadores de Fármacos/química , Sistemas de Liberación de Medicamentos , Estabilidad de Medicamentos , Geles , Ibuprofeno/química , Tamaño de la Partícula , Porosidad , Dióxido de Silicio/química , SolubilidadRESUMEN
Many individuals with hepatitis C virus (HCV) infection are undiagnosed. This study evaluates a risk assessment questionnaire, developed for use online to target blood-screening for HCV. Two hundred and eighty-nine patients with known HCV status completed a written questionnaire on prominent HCV risk factors. Questionnaires generated advice to seek testing if at least one risk factor was reported. Agreement of the testing advice with the HCV status of respondents was evaluated. Subsequently, we validated our questionnaire among 985 patients of an outpatient clinic for sexually transmitted infections. The post-test-probability-of-disease (PTPD) and diagnostic gain (PTPD minus prior probability of disease) were calculated. The questionnaire's sensitivity and specificity were 84.6% and 63.8%, respectively, and higher in the STI clinic patients. The PTPD of positive testing advice was 72.5% given HCV prevalence of 53.0%, yielding a diagnostic gain of 19.5%. Applying the estimated prevalence in the general Dutch population (0.1-0.4%), and the anticipated prevalence in the online project (1.0-6.0%), yielded diagnostic gains of 0.13-0.53% and 1.3-7.0%, respectively. We conclude that our questionnaire succeeded in selecting at-risk individuals as its testing advice agreed well with the HCV status. We suggest that the questionnaire be used online as a selection tool for HCV blood-screening in the general population.
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Hepacivirus/aislamiento & purificación , Hepatitis C/diagnóstico , Tamizaje Masivo/métodos , Medición de Riesgo/métodos , Encuestas y Cuestionarios , Adulto , Femenino , Hepatitis C/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Países Bajos/epidemiología , Sensibilidad y EspecificidadAsunto(s)
Infecciones por VIH/complicaciones , Virus de la Hepatitis B/aislamiento & purificación , Hepatitis B/complicaciones , Adulto , Diagnóstico Diferencial , Virus de la Hepatitis B/clasificación , Virus de la Hepatitis B/genética , Virus de la Hepatitis B/inmunología , Humanos , Pruebas de Función Hepática , Masculino , Países Bajos , Transaminasas/sangreRESUMEN
UNLABELLED: The objective was to study the usefulness of routine measurement of liver enzymes (ASAT, ALAT, alkaline phosphatase, gamma-GT), and total protein (TP) and albumin (Alb) in a general medicine outpatient clinic. A prospective study was made of consecutive patients who were classified according to whether or not an indication for the tests was present. All six tests were measured in all patients. Physicians were kept unaware of the results of tests in patients with no indication for ordering the test. The setting was a general internal medicine outpatient clinic in a 850-bed teaching hospital which serves as a referral clinic for general practitioners. There were 615 consecutive patients who were all new referrals to the outpatient clinic. The results of all patients with no indication for the test but who had abnormal results were presented to a panel of three experienced internists who decided whether the results had any clinical importance. Repeat measurements of the tests or follow-up results were obtained in all these patients. Seventy-eight of 320 patients in whom no indication for the test for liver enzymes existed had abnormal results. In only six of these (1.9%) were the abnormalities of clinical significance. In 56 of 449 patients in whom no indications were present for TP and Alb measurement the results were abnormal. In only 2 (0.4%) was this clinically important. CONCLUSION: the routine measurement of these six tests in general medicine outpatient clinics should be abandoned because of the low yield.
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Proteínas Sanguíneas/análisis , Pruebas Diagnósticas de Rutina/estadística & datos numéricos , Hígado/enzimología , Albúmina Sérica/análisis , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Países Bajos , Servicio Ambulatorio en Hospital , Estudios ProspectivosRESUMEN
This report is about a 71-yr-old woman who suffered from acute liver failure, induced by the nonsteroidal antiinflammatory drug, pirprofen. She presented with jaundice 6 weeks after starting treatment with 800 mg pirprofen daily. She is the fifth patient described in the literature to die from pirprofen-induced hepatotoxicity.
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Antiinflamatorios no Esteroideos/efectos adversos , Enfermedad Hepática Inducida por Sustancias y Drogas/etiología , Fenilpropionatos/efectos adversos , Adulto , Anciano , Antiinflamatorios no Esteroideos/administración & dosificación , Enfermedad Hepática Inducida por Sustancias y Drogas/mortalidad , Enfermedad Hepática Inducida por Sustancias y Drogas/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fenilpropionatos/administración & dosificaciónRESUMEN
Patients with monosymptomatic celiac disease (CD) can escape diagnosis for a long period. Anemia is a common finding in CD, although anemia as the sole symptom is relatively unknown. We report on three patients who presented with iron deficiency anemia and no other symptom, in whom CD was considered and diagnosed several to many years after the anemia was documented.
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Anemia Hipocrómica/diagnóstico , Enfermedad Celíaca/diagnóstico , Anemia Hipocrómica/etiología , Anemia Hipocrómica/terapia , Enfermedad Celíaca/complicaciones , Enfermedad Celíaca/dietoterapia , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
A case is described with pathological gastro-oesophageal reflux and nighttime bronchial asthma. Treatment with omeprazole resulted not only in improvement of gastro-oesophageal reflux but also in alleviation of asthmatic symptoms and increases in expiratory peak flow values. The possible pathophysiological mechanisms whereby gastro-oesophageal reflux may induce or aggravate asthmatic symptoms are discussed. At present it is not yet possible to predict which patients with bronchial asthma will benefit from antireflux therapy with respect to their pulmonary condition, but such treatment is warranted in all patients with bronchial asthma and proven pathological gastro-oesophageal reflux.
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Asma/tratamiento farmacológico , Reflujo Gastroesofágico/tratamiento farmacológico , Omeprazol/administración & dosificación , Esquema de Medicación , Estudios de Seguimiento , Humanos , Ápice del Flujo Espiratorio/efectos de los fármacos , Capacidad Vital/efectos de los fármacosRESUMEN
A 25-yr-old man suffered from severe nocturnal asthma, which was shown to be provoked by pathological gastro-oesophageal reflux. A dramatic, immediate improvement of his pulmonary condition was achieved by treatment with omeprazole after failure of other therapeutic measures, including high doses of ranitidine.