Luis Hidalgo

To assess the age at menopause (AM) in Latin America urban areas. A total of 17,150 healthy women, aged 40 to 59 years, accompanying patients to healthcare centers in 47 cities of 15 Latin American countries, were surveyed regarding their age, educational level, healthcare coverage, history of gynecological surgery, smoking habit, presence of menses, and the use of contraception or hormone therapy at menopause. The AM was calculated using logit analysis. The mean age of the entire sample was 49.4 +/- 5.5 years. Mean educational level was 9.9 +/- 4.5 years, and the use of hormone therapy and oral contraception was 22.1% and 7.9%, respectively. The median AM of women in all centers was 48.6 years, ranging from 43.8 years in Asuncion (Paraguay) to 53 years in Cartagena de Indias (Colombia). Logistic regression analysis determined that women aged 49 living in cities at 2,000 meters or more above sea level (OR = 2.0, 95% CI: 1.4-2.9, P…

The prevalence of the metabolic syndrome increases with age and after the onset of menopause, and may explain in part the apparent acceleration of cardiovascular disease in postmenopausal women. To determine the prevalence of metabolic syndrome and related risk determinants among postmenopausal women in Ecuador. Postmenopausal women >or=40 years of age, non-users of hormone therapy and with an intact uterus, were asked to participate in a metabolic syndrome screening and educational program at the Institute of Biomedicine of the Universidad Católica of Guayaquil, Ecuador. Sociodemographic data, waist circumference and blood pressure measurements were recorded, and a fasting blood sample obtained for serum glucose and lipid profile determinations. Woman were counseled and managed according to the results. Metabolic syndrome was defined in accordance with the criteria of the Third Adult Treatment Panel (ATP III). Three hundred and twenty-five postmenopausal women entered the program. Mean (+/-standard deviation) age was 55.9 +/- 8.1 years, 53.5% of them were aged >or=54 years (median). The prevalence of metabolic syndrome, according to ATP III criteria, was 41.5%. Using the same criteria, 38.8%, 16.6%, 56.9% and 54.2% of the women presented with hypertension, diabetes, hypertriglyceridemia and abdominal obesity, respectively. More than 40% of women determined to have hypertension or diabetes lacked knowing so. Logistic regression analysis determined that age increased the risk of presenting hypertension and diabetes (odds ratio (95% confidence interval): 2.0 (1.2-3.2) and 1.6 (0.9-3.0), respectively, p < 0.05), entities which in turn duplicated the risk of having high triglyceride levels. Sedentary women with <5 years since menopause onset were at higher risk of having abdominal obesity, which was directly related to diabetes and hypertension. In this postmenopausal Ecuadorian population the prevalence of the metabolic syndrome was high and its determinant factors related to age, time since menopause onset and sedentary habits. Because of the implications for cardiovascular risk, counseling programs directed toward high-risk populations should be encouraged.

Pre-term birth is a world wide health problem, and although fetal fibronectin (fFN) testing has proven its clinical utility in developed countries, this remains to be determined in the developing world. To evaluate the clinical utility of fFN in predicting pre-term birth in a low socio-economic, non-profit hospital setting. In this observational study, pregnant women < 37 completed weeks with symptoms suggestive of threatened pre-term labour (painful regular contractions and cervical modifications) were tested with the fFN test, admitted for management and subsequently followed up every 2 weeks until the end of gestation. Delivery rates <35 and <37 weeks and within 7, 14 and 21 days were compared among women with positive and negative results. During the study period, 180 gravids were tested for fFN [52 positives (28.9%) and 128 negatives (71.1%)]. In the positive fFN group, the admission-to-delivery interval was significantly shorter, whereas delivery rates before 35 and 37 weeks and within 7, 14 and 21 days were found to be higher. Neonates delivered from positive fFN women had lower weight and gestational age as well as higher rates of adverse neonatal outcomes and admissions to the intensive care unit. Finally, fFN testing was useful in predicting delivery at less than 37 and 35 weeks (sensitivity: 76, 100%; specificity: 89.2, 76.2%; positive predictive value: 73.1, 23.1%; negative predictive value: 90.6, 100%, respectively) and within 7, 14 and 21 days (sensitivity: 75, 66 and 65.6%; specificity: 78.2, 86.6 and 91.4%; positive predictive value: 34.6, 67.3 and 80.8%; negative predictive value 95.3, 85.9 and 82.8%, respectively). In this low-income healthcare scenario, testing for fFN was effective in assessing the risk of pre-term birth; we propose that testing be implemented as a hospital policy suggesting that negative resulting women be managed in an ambulatory fashion.

In South America, and particularly Ecuador, cesarean section rates have risen markedly over the past five years. The associated increases in maternal morbidity and healthcare costs indicate the need for alternative strategies. Operative vaginal delivery is minimally utilized in Ecuador, as neither vacuum nor forceps have been available. As vacuum delivery was recently introduced to our clinical service, we sought to examine our initial experiences (i.e., maternal and neonatal outcome) with operative vaginal delivery for prolonged second stage of labor. Following an initial educational program at the Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil, Ecuador, vacuum extraction cups (Mityvac, Cooper Surgical) were offered to laboring women with term singleton gestations and cephalic presentations no higher than +3 station. Maternal and neonatal data were analyzed. During the study period, 100 vacuum applications were performed on laboring women complicated with prolonged second stage of labor. Mean maternal age was 23.8 +/- 6.4 years (range 14-41 years) with 57% of patients nulliparous. Left anterior and right posterior fetal positions were the most frequent (85% and 11%, respectively). Maternal complications included need for blood transfusion (1%), shoulder dystocia (1%) and perineal tears (first degree 6%, second degree 5%). Vaginal delivery was successful in 97% of cases. Among neonates, the average weight was 3149 +/- 410 g, with 10% neonates small for gestational age and 5% large for gestational age. Only 1% of infants presented an Apgar score <7 at 5 min. There were no scalp lacerations, cephalohematomas, or subgaleal bleeds. In this initial observational study, vacuum extraction for prolonged second stage was safe and effective. We propose that the introduction of operative vaginal delivery to developing countries will mitigate rising cesarean section rates.

Objective The purpose of this study was to determine obstetrical and neonatal outcome among early adolescent pregnancies (≤15 years). Method We compared obstetrical and neonatal outcome of early adolescent nulliparas with outcome of nulliparous women aged 20–30 years. Results Two hundred and one (201) early adolescent nulliparous patients of low socio-economic status were enrolled at the Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil-Ecuador, and matched for gestational age with 201 low socio-economic nulliparous controls aged 20–30. Mean maternal age of the adolescent group was 14.2±0.6 years. The incidence of cervicovaginal infections during current pregnancy was significantly higher among adolescents (trichomoniasis: 11.4% vs. 5% and candidiasis: 27.8% vs. 12.4%, p p p Conclusion Pregnancy in young adolescents (≤15 years) of low socio-economic status did not impose adverse obstetrical outcome, however it did increase the risk for low birth weight, adverse neonatal outcome and cervicovaginal infections.

The unexpected results of the Women's Health Initiative study have decreased the use of conventional hormone therapy (HT), changing physicians' and patients' attitudes towards HT and increasing their interest in alternative options. The present study aimed to evaluate the effect of isoflavones contained in red clover extracts (Trifolium pratense) on menopausal symptoms, lipids and vaginal cytology in menopausal women. Sixty postmenopausal women aged >40 years, non-users of HT, with Kupperman index score 15, were double-blindly randomized to receive either a commercially available red clover isoflavone supplement (80 mg/day) or placebo for 90 days. Subsequently, after a 7-day washout period, subjects switched to receive the opposite treatment for a further 90 days. Kupperman index score was determined and fasting blood and vaginal cytologic sampling performed at baseline, 90 and 180 days. Fifty-three women (88.3%) completed the trial. Mean age was 51.3 +/- 3.5 years, 69.7% of the women were aged 50 years or more. There was no significant effect on body mass index, weight or blood pressure after either treatment phase. Baseline Kupperman index score decreased significantly after each treatment phase, with the decrease more pronounced after the isoflavone phase (baseline: 27.2 +/- 7.7; after isoflavone: 5.9 +/- 3.9; after placebo: 20.9 +/- 5.3, p < 0.05). Red clover isoflavone supplementation significantly decreased the rate of menopausal symptoms and had a positive effect on vaginal cytology as expressed by improvement in karyopyknotic, cornification and basal cell maturation indices. Mean total cholesterol, low-density lipoprotein-cholesterol and triglyceride levels also decreased; however, only the latter was significantly lower compared with placebo. Compared with placebo, red clover isoflavone supplementation in postmenopausal women significantly decreased menopausal symptoms and had a positive effect on vaginal cytology and triglyceride levels.

Some human organ transplants deteriorate slowly over a period of years, often developing characteristic syndromes: transplant glomerulopathy (TG) in kidneys, bronchiolitis obliterans in lungs, and coronary artery disease in hearts. In the past, we attributed late graft deterioration to "chronic rejection", a distinct but mysterious immunologic process different from conventional rejection. However, it is likely that much of chronic rejection is explained by conventional T-cell-mediated rejection (TMR), antibody-mediated rejection (AMR), and other insults. Recently, criteria have emerged to now permit us to diagnose AMR in kidney transplants, particularly C4d deposition in peritubular capillaries and circulating antibody against donor human leukocyte antigens (HLA). Some cases with AMR develop TG, although the relationship of TG to AMR is complex. Thus, a specific diagnosis of AMR in kidney can now be made, based on graft damage, C4d deposition, and donor-specific alloantibodies. Criteria for AMR in other organs must be defined. Not all late rejections are AMR; some deteriorating organs probably have smoldering TMR. The diagnosis of late ongoing AMR raises the possibility of treatment to suppress the alloantibody, but efficacy of the available treatments requires further study.

ABSTRACT Aim To investigate the use of the monoclonal antibody (Ab) WR18 and its ability to label DR, DQ and DP antigens. Methods Class II single antigen beads (SAB) (LabScreen®, One Lambda Inc.) were stained with monoclonal Ab as indicated in Table 1. A PE labelled anti-mouse conjugate Ab was used to demonstrate the monoclonal antibody on the beads. (Jackson Immunoresearch, cat# 115-116-071). Beads were acquired on a Luminex® 200™ instrument and results were analyzed in Microsoft Excel® and Graphpad Prism®. Results WR18 labelled all DR, DQ and DP beads. The labelling was very similar to each individual monoclonal with the exception of one of the DRB3 beads (bead 89); WR18 labels this DRB3 bead better than L243. The DQ Ab chosen did not label the DQ2 antigens in the panel thus these beads were excluded from analysis. The Spearman Correlation Coefficients are 0.78, 0.85, and .91 for the DR, DP and DQ Ab respectively as compared to WR18, p < 0.0001 for each. An example of the staining can be seen in Fig. 1. The DP antigens had higher MFI values with the WR18 Ab than the B7/21 Ab Fig. 1. WR18 vs L243 labelling of DR SAB. Figure optionsView in workspace Conclusions WR18 monoclonal Ab appears to label HLA DR, DP and DQ as expected and is a useful tool for measuring and detecting class II HLA.

ABSTRACT Aim To investigate the use of an antigen density correction factor (ADCF) for class I and II single antigen beads (SAB). Methods Class I and II SAB (One Lambda Inc) were labelled using mouse monoclonal antibodies (Ab) specific for Class I (W6/32) and Class II (WR18) HLA antigens (Ag). The WR18 Ab reacts with HLA DR, DQ and DP. A PE labelled anti-mouse Ab was used to detect the monoclonal Ab (Jackson Immunoresearch). Weak and strong titres of the W6/32, WR18 and PE conjugate Ab were evaluated. Consistently lowest ranked beads (LRB) were assigned a ratio of 1.0 for each SAB kit. A ratio to the LRB was determined by averaging the LRB value for high and low titres of Ab. Using the LRB, the ADCF was determined and applied to patient antibody results (n = 20, 6 class I SAB, 14 class II SAB) to investigate whether or not results appeared to be more standardized. Beads with the same antigen typing were compared. Results Ag density of the Class I and II beads is variable. High titre W6/32 MFI values ranged from 10,000 to 19,500 vs. lower titre MFI values from 3400 to 8600. High titre WR18 MFI valures ranged from 9742 to 20,824 vs lower titre values from 2158-12,705. The ADCF varied from 1-2.39 (W6/32) and 1-2.78 (WR18). There is greater variability at with weaker Ab staining as compared to high titre of Ab. Adjusted patient MFI values still show variability in staining between same antigen beads although some beads are now more positive than others. Conclusions There is a range of Ag density on the class I and II SAB. The variability in staining appears to be greater with weaker dilutions of Ab. Adjusting for this variability in the Ag density may not standardize the patient sera reactivity thus we are unsure of the utility of this adjustment ratio. Comparison of the ADCF patient MFI results to flow crossmatch results may reveal if the adjusted MFI results are more clinically useful. It is not difficult to measure the antigen density on SAB and we will use this information to assess new lot numbers of SAB.

ABSTRACT Aim To examine the differences in HLA surface expression between memory and non-memory T and B cells in PBL and spleen. Methods Staining procedure followed our standard method for flow cytometry crossmatches but pronase-treated and untreated cells were analyzed. HLA class I and HLA-DR expression was assessed by staining PBL (n = 9) or splenocytes (n = 10) with W6/32 and L243, respectively. Bound antibody was detected with goat anti-human IgG FITC and analyzed by flow cytometry. CD27 was used as a T and B cell memory marker. Results CD27 is protein that was difficult to detect in pronase-treated cells so the analysis was performed on untreated cells. Memory T cells (CD27hi) in spleen displayed nearly equal amounts of HLA class I as compared to non-memory (CD27lo) T cells (Fig. 1). In PBL, memory T cells expressed modestly lower HLA class I than non-memory T cells. The pattern of B cell class I expression differed. The majority of T cells in both PBL and spleen were memory T cells. Memory B cells in spleen and PBL consistently expressed higher levels of class I compared to non-memory (p < 0.0001 for both, paired t-test). HLA-DR levels of expression followed the same pattern of expression as class I on B cells. The percentages of memory B cells were not as dominant as those for memory T cells, particularly in spleen. Figure optionsView in workspace Conclusions Memory B cells, unlike memory T cells, have much higher expression of HLA class I and HLA-DR. Although not a major cell type in PBL, B cells make up a significant portion of cells in spleen (and lymph nodes). Thus, finding an alternative to pronase in order to identify memory B cells may enhance the sensitivity of flow cytometry crossmatches.