Five-year outcomes of rapid-deployment aortic valve replacement with the Edwards Intuity valve

BACKGROUND

This report presents 5-year outcomes of the rapid-deployment Edwards Intuity valve in a prospective, single-center study.

METHODS

All patients who underwent an aortic valve replacement (AVR) with an Edwards Intuity bioprosthesis at La Timone Hospital, Marseille, France, from July 2012 to June 2015 were assessed over a 5-year follow-up period. The primary outcome was overall mortality at 5 years. Secondary outcomes were reoperation, overall mortality and stroke, cardiovascular mortality, composite endpoints defined by the updated Valve Academic Research Consortium-2 (VARC-2), periprosthetic regurgitation, prosthesis-patient mismatch, and the need for new pacemaker implantation.

RESULTS

In total, 170 consecutive patients were assessed, of which 67.1% were males. The mean age was 76 years, mean EuroSCORE II was 3.5% and 5-year overall mortality was 12.4%. At 5 years, reoperation was 2.9%, overall mortality and stroke was 4.1% per patient-year, and cardiovascular mortality was 4.7%. VARC clinical efficacy and VARC time-related valve safety were achieved in 46.0% and 59.9% of patients, respectively. At one month VARC device success was 71.2% and VARC early safety was 87.1%. At one year, mild and moderate periprosthetic regurgitation were 2.4% and 0.6%, respectively, and moderate and severe prosthesis-patient mismatch were 18.8% and 4.8%, respectively. Conduction disturbances needing new PPI occurred in 3.5% patients.

CONCLUSION

The 5-year outcomes of AVR with the Edwards Intuity valve system demonstrate satisfactory midterm safety and excellent haemodynamic performance.

P1000Aetiology and efficacy of atrial fibrillation ablation in young adults

Introduction

Little is known regarding the aetiology or outcome of atrial fibrillation (AF) occurring in young adults. This retrospective analysis was performed to explore the demographics and efficacy of AF ablation in this population.

Methods

Patients were included who had undergone ≥1 AF ablation under the age of 40 between 2006-2018. Recurrence was defined as return of either documented AF or previous symptoms for >30s following a 3-month blanking period. Initial exploratory co-variates were included in a univariate analysis and those terms with P-value of <0.1 were then used to generate a Cox proportional-hazards multivariate model.

Results

124 patients (33.6 ± 4.7 yrs, 77% men), initially presenting with paroxysmal AF (pAF; n = 97) or persistent AF (n = 27), underwent 175 AF ablation procedures. 22.6% (n = 28) also had atrial flutter. Time from symptom onset to first ablation was 50.7 ± 46.2 months. Relevant cardiovascular-related demographics were analysed: hypertension in 8.9% (n = 11); diabetes in 1.6% (n = 2); positive family history of AF in 12.9% (n = 16); and family history of sudden cardiac death in 2.4% (n = 3). Mean CHA2DS2-VASc score was 0.35. Of those patients with documented echocardiogram imaging (n = 91), 26.4% (n = 24) had LA dilatation and 6.6% (n = 6) had LV dysfunction. Patients with LA dilatation underwent more ablations (2.3 ± 0.3) compared to controls (1.5 ± 0.1; p < 0.001).

Ablation strategy was pulmonary vein isolation (PVI) only in 67.2% (n = 119), with additional ablation in the remaining: roof line in 18.9% (n = 33); cavotricuspid isthmus line in 13.1% (n = 23); mitral isthmus line in 2.3% (n = 4); superior vena cava isolation in 2.3% (n = 4); complex fractionated atrial electrograms in 14.9% (n = 26). Mean procedure time was 155 ± 41 min, mean ablation time was 1657 ± 991 s and mean fluoroscopy time was 32.6 ± 23.4 min. General anaesthesia was used in 43.4% (n = 76). Complications included femoral haematoma (n = 2), tamponade (n = 1) and pulmonary vein stenosis (n = 2).

90 days of follow-up was available for 137 procedures performed for pAF (n = 105) and persistent AF (n = 32). For pAF, overall recurrence was 61.9% for first ablations and 62.9% overall. Recurrence was 56.3% for persistent AF.

Factors significantly associated with increased AF recurrence in univariate analysis were

male gender (hazard ratio (HR) 2.3, 95% confidence interval (CI): 1.2-4.4, p = 0.011), hypertension (HR 0.5, CI: 0.2-1.1, p = 0.067), family history of sudden cardiac death (HR 6.8, CI: 1.6-29.0 , p = 0.010) and enlarged LA size (HR 2.2, CI: 1.3-3.6, p = 0.003). In multivariate analysis, the only significant predictor of poor outcome was enlarged LA size (HR 2.0, 95% CI: 1.2-3.5, p = 0.011).

Conclusions

Young patients with AF may have structurally abnormal hearts, and therefore do not only present with lone AF. LA size may be used as a predictor for success. Surveillance imaging may be useful to detect future structural change, which will be the subject of future prospective studies.

Abstract Figure. AF ablation recurrence in young adults

P1381Improved outcome in ablation of ventricular tachycardia in patients with structural heart disease under general anaesthetic

Background

Catheter ablation is an important adjunct to device implantation for secondary prevention of ventricular tachycardia (VT). However, several factors may influence the success of ablations in terms of long-term freedom from VT recurrence. A thus far little examined factor is the use of general anaesthetic (GA) versus conscious sedation during the procedure, which has been shown to improve outcomes in persistent atrial fibrillation (AF) ablation.

Methods

Patients with structural heart disease VT undergoing ablations from January 2015 to March 2019 were retrospectively followed up at a single centre. End points were recurrent VT or device therapy (shock or anti-tachycardia pacing) at one year. Hazard ratios (HR) were generated using a multivariate Cox-regression proportional hazards model including variables of age at ablation, sex, amiodarone use at time of ablation, scar age, left ventricular ejection fraction, use of GA, and diagnosis of: diabetes mellitus (DM), hypertension (HTN), renal impairment or AF.

Results

79 patients (74 male, mean age 68.2+/- 10.3 years) were included. A substrate-based strategy of late potential ablation was employed. 69 had ischaemic and 10 had non-ischaemic cardiomyopathy. Mean scar age was 13.8 +/- 9.8 years; EF was 40-50% in 27 patients, 30-40% in 26 and < 30% in 26. 37 patients had implantable cardioverter defibrillators and 30 had cardiac resynchronisation therapy (CRT) defibrillator devices, 1 had a CRT- pacemaker device and 4 had dual chamber pacemakers. Comorbidities were: DM (16), HTN (31), renal impairment (13), AF (31). 62 patients (79.5%) were on amiodarone at the time of ablation. Mean procedure duration was 234.8 +/- 44.5 min and mean radiofrequency energy application time was 2247 +/- 862 s. 61 were first procedures and 18 were repeat procedures. One patient suffered a complication of groin haematoma. 62 patients (78.5%) underwent VT ablation under GA and 17 (21.5%) under sedation of midazolam and fentanyl. Patient characteristics did not differ between groups. Significant factors which increased freedom from VT recurrence or device therapy were HTN (88.9% vs 59.4%, HR 0.72, 95% confidence interval (CI): 0.007-0.75, p= 0.028), amiodarone treatment (50.0% vs 76.3%, HR 0.036, 95% CI: 0.003-0.404, p = 0.036) and ablation under GA rather than sedation (50.0% vs 75.0%, HR 0.055, 95% CI: 0.006-0.495, p = 0.01) (Fig 1).

Conclusions

In patients with structural heart disease undergoing VT ablation, outcomes are improved with the use of GA over conscious sedation.

Abstract Figure 1

Rate of evolutionary change in cranial morphology of the marsupial genus Monodelphis is constrained by the availability of additive genetic variation

We tested the hypothesis that the rate of marsupial cranial evolution is dependent on the distribution of genetic variation in multivariate space. To do so, we carried out a genetic analysis of cranial morphological variation in laboratory strains of Monodelphis domestica and used estimates of genetic covariation to analyse the morphological diversification of the Monodelphis brevicaudata species group. We found that within-species genetic variation is concentrated in only a few axes of the morphospace and that this strong genetic covariation influenced the rate of morphological diversification of the brevicaudata group, with between-species divergence occurring fastest when occurring along the genetic line of least resistance. Accounting for the geometric distribution of genetic variation also increased our ability to detect the selective regimen underlying species diversification, with several instances of selection only being detected when genetic covariances were taken into account. Therefore, this work directly links patterns of genetic covariation among traits to macroevolutionary patterns of morphological divergence. Our findings also suggest that the limited distribution of Monodelphis species in morphospace is the result of a complex interplay between the limited dimensionality of available genetic variation and strong stabilizing selection along two major axes of genetic variation.

One year of Lamivudine therapy for portuguese patients with chronic hepatitis B

OBJECTIVE

To assess the efficacy of lamivudine treatment on hepatitis B e antigen (HBeAg) and/or hepatitis B surface antigen (HBsAg) seroconversion, on other virological and serological markers of response including hepatitis B virus (HBV) DNA and serum aminotransferases, and the safety of lamivudine treatment in hepatitis B patients.

PATIENTS

This phase III open-label study evaluated the virological and biochemical response to lamivudine in 70 Portuguese patients with HBeAg positive chronic hepatitis B. Patients were treated with lamivudine 100mg once daily for 12 months.

METHODS

Antiviral activity was assessed by measuring alanine aminotransferase (ALT)/aspartate aminotransferase (AST) levels at all protocol visits, and hepatitis B serology and HBV DNA were performed at baseline and at month 12 visits. Evaluation of safety and tolerance was based on clinical adverse events and laboratory analyses.

RESULTS

The primary endpoint was virological response at month 12, defined as loss of detectable HBeAg from serum with a reduction of HBV DNA to undetectable levels, and this was observed in 19/69 (27.5%) of patients. Almost half of the patients were HBV DNA negative by this time. Mean ALT values decreased steadily during treatment and by 12 months 61% of patients had values within the normal range. HBeAg seroconversion (HBeAg negative, HBeAb positive) was achieved in 27.9% of patients by 12 months, although all patients remained HBsAg positive.

CONCLUSION

Lamivudine was well tolerated and the incidence of adverse events was similar to those reported in previous studies. Lamivudine treatment resulted in virological and biochemical improvements in HBeAg positive chronic hepatitis B patients, with HBeAg seroconversion in one-third of patients.

Fatty bronchogram: a sign of cystic teratoma rupture in the lung

A 47-year-old man was admitted to our hospital for septic fever. Multidetector computed tomography showed a pulmonary cavitated consolidation that was partially filled by low-density material and an interrupted rim of soft tissue in adjacent mediastinum, lining an inhomogeneous fat density area. Lung consolidation presented a bronchogram fluid sign with a -40 Hounsfield unit density value, which indicated a fatty bronchogram. Mediastinal cystic teratoma rupture in the lung was derived from a bacterial infection, with the lipoid material pouring into the lung and its drainage bronchus.

Characterization of Spin on Glass Using Thermo Analytical Techniques and Ftir Spectroscopy

The curing of a commercial ethoxymethyl-phosphosiloxane at different temperatures and under various gas ambients was characterised using NMR, thermoanalytical techniques, and FTIR spectroscopy. DSC (Differential Scanning Calorimetry) and DTG (Differential Thermo Gravimetry) were employed to characterize the reactions that occur during thermal treatments in O2 or N2 atmospheres. FTIR spectroscopy and CP (Cross Polarization) 133C - NMR were used to detect the presence of the hydroxyl and organic groups in the cured samples. The experimental results identified three different temperatures (400,580,700°C) that define important stages of the curing reaction. In particular, for annealing at temperatuires up to 580°C in 02, DSC, DTG and FTIR spectra showed the elimination of the organic groups. However, when the annealing was carried out in N2 up to 700°C, these groups are retained.

Influenza A virus: radiological and clinical findings of patients hospitalised for pandemic H1N1 influenza

Purpose

This paper describes the radiological and clinical findings identified in a group of patients with H1N1 influenza.

Materials and methods

Between May and mid-November 2009, 3,649 patients with suspected H1N1 influenza presented to our hospital. Our study population comprised 167 (91 male, 76 female patients, age range 11 months to 82 years; mean age 29 years) out of 1,896 patients with throat swab positive for H1N1 and clinical and laboratory findings indicative of viral influenza. All 167 patients were studied by chest X-ray (CXR), and 20 patients with positive CXR and worsening clinical condition also underwent computed tomography (CT). The following findings were evaluated on both modalities: interstitial reticulation (IR), nodules (N), ground-glass opacities (GGO), consolidations (CONS), bacterial superinfection and pulmonary complications.

Results

Ninety of 167 patients had positive CXR results. Abnormalities identified on CXR, variously combined and distributed, were as follows: 53 IR, 5 N, 13 GGO, 50 CONS; the predominant combination was represented by six GGO with CONS. Of the 20 CXR-positive cases also studied by CT, 17 showed pathological findings. The abnormalities identified on CT, variously combined and distributed, were as follows: 14 IR, 2 N, 5 GGO; the predominant combination was 10 GGO with CONS. Despite the differences between the two modalities, the principle radiological findings of bacterial superinfection were tree-in-bud pattern, consolidation with air bronchogram, and pleural and pericardial effusion. Fifteen of the 20 patients studied by both CXR and chest CT showed respiratory complications with bilateral and diffuse CONS on CXR and CT. Six of 15 died: 4/6 of acute respiratory distress syndrome and 2/6 of multiple organ failure.

Conclusions

Our study describes the radiological and clinical characteristics of a large population of patients affected by H1N1 influenza. CXR and chest CT identified the site and extent of the pulmonary lesions and documented signs of bacterial superinfection and pulmonary complications.

Spontaneous Resolution of Eosinophilic Granuloma in a Patient with a Psychotic Disorder

A 16-year-old female who manifested psychotic symptoms underwent CT and MRI for the evaluation of an incidentally discovered asymptomatic palpable mass of the right occipital region of the skull. The correlation between clinical and radiological data and biopsy data led to the diagnosis of eosinophilic granuloma. The radiological finding is discussed and reviewed in relation to clinical aspects and literature data.

Skin reactivity to aeroallergens is reduced in human T-lymphotropic virus type I-infected healthy blood-donors (asymptomatic carriers)

BACKGROUND

A type 2 immune response, characterized by high levels of interleukin-4 and immunoglobulin E synthesis is a hallmark of respiratory allergic diseases. Individuals infected with human T-lymphotropic virus type I (HTLV-I) virus have spontaneous T-cell proliferation and increased interferon gamma production, which are immunological functions associated with a type 1 immune response.

OBJECTIVE

To determine the frequency of asthma and rhinitis symptoms and immediate skin reactivity to aeroallergens in HTLV-I infected individuals, compared with noninfected subjects.

METHODS

Cross sectional study of 101 HTLV-I infected and 101 control uninfected blood donors, assessed by enzyme-linked immunosorbent assay and Western blot assays. The subjects were age and sex-matched, identified as presenting allergy history by questionnaire, which was complemented by a complete clinical examination and skin prick tests for aeroallergens.

RESULTS

The frequency of atopy was lower in infected than uninfected subjects, 14.9 and 29.7% (P = 0.017), respectively. Skin reactivity to Dermatophagoides pteronissynus, Dermatophagoides farinae and Blomia tropicalis were the most frequently observed among all the tested antigens in both groups. Skin reactivity to histamine was also reduced in the infected individuals compared with uninfected subjects (medians 4.0 vs 5.0, respectively; P < 0.0001). Infection by HTLV-I was found to be a factor of protection to atopy (RP 0.44; P = 0.005).

CONCLUSIONS

The HTLV-I infection reduces the frequency of respiratory allergy and skin reactivity to aeroallergens.

Paradoxical coexistence of atopic asthma and Human T-Lymphotropic Virus Type I (HTLV-I) infection: a case report

In this case report, the authors report the presence of two supposedly antagonic immune diseases in the same patient. The patient is a 45-year-old white woman with a history of asthma and allergic rhinitis for the last 10 years. Asthmatic symptoms were present and were triggered after exposure to dust and mold. Her Human T-Lymphotropic Virus Type I (HTLV-I) seropositive status was detected by chance five years ago during a routine screening for blood donation. Skin prick tests were positive for Dermatophagoides pteronyssinus, Dermatophagoides farinae and Blomia tropicalis. Cytokine levels in unstimulated cultures were: IFNgamma= 1195 pg/ ml, TNFalpha = 460 pg/ml, IL5 = 41 pg/ml and IL10 = 265 pg/ml.

Small dose of recombinant factor VIIa (rFVIIa) to perform percutaneous liver biopsies in cirrhotic patients

Low levels of vitamin K-dependent coagulation factors, synthesized in the liver, play a key role in the hypocoagulable state of end-stage liver disease patients. Recombinant factor VII (rFVIIa) has been developed for, and currently is used in the treatment of patients with hemophilia A and B with inhibitors. Some experience was gained with rFVIIa in liver diseases since 1995. We used a low dose of rFVIIa to perform percutaneous liver biopsy in three patients, all of them with abnormal coagulation, impeditive of the percutaneous liver biopsy. The first one was a 29 years old man with alcoholic cirrhosis and a liver nodule; the second was a 32 years old man with post hepatitis C cirrhosis and excessive alcohol intake; the third was a 53 years old man with chronic hepatitis C and a congenital deficit of factor VII. A single dose of 5 micrograms/Kg of rFVII administered before liver biopsies raised levels of factor VII to acceptable values during more than 5 hours in the first two patients. We conclude that a small dose of rFVIIa can be enough to correct the abnormal coagulation of cirrhotic patients, permits percutaneous liver biopsy, and is cost-effective, compared to transjugular access.

[Primary neoplasm of unknown origin]

Cancers of unknown primary site constitute a heterogeneous group having in common their biological behaviour. We have analysed patients with cancer of unknown primary site admitted to University Hospital of Coimbra/Internal Medicine Service III from 1st January of 1992 to 30th June of 1998. The study included 26 patients corresponding to a prevalence of 2.5% malignant neoplasias; the median age of affected patients was 64 years old with a male-to-female ratio of 4.2:1. The most frequent histological type was well differentiated and moderately well differentiated adenocarcinoma, 46.1% of all cases. Three years global survival rate was 3.9%. The herein-reported prevalence is comparable to that found in recent literature, showing a good diagnostic skill. As expected, the prognosis was poor, revealing the disease's aggressiveness and the lack of efficient therapy in the majority of case.

[Prevalence of markers of hepatitis B infection in the adult population of the district of Coimbra]

AIM

To assess the prevalence of hepatitis B markers in the adult population of the Coimbra district, in the central region of Portugal.

METHODS

The study included 657 subjects chosen aleatorily from 4 characteristic councils of the Coimbra district. They were questioned regarding risk factors and blood samples were taken for HBsAg, anti-HBs and anti-HBc testing. Anti-HCV was previously determined and it was positive in 0.45% of the cases.

RESULTS

HBsAg was found in 0.91%. Anti-HBs and anti-HBc were both positive in 6.08%, anti-HBc without anti-HBs was found in 1.82% and anti-HBs without anti-HBc was found in 1.67% (11 cases, 8 vaccinated). The general prevalence of hepatitis B markers was 9.3%. Higher prevalences were found in the subjects over 50 years of age, 13.5% (p < 0.05), and in the urban area, 13.2% (p < 0.05).

CONCLUSIONS

1. The HBsAg prevalence in our region is 0.9%; 2. The general prevalence of hepatitis B markers is 9.3%; 3. HBsAg prevalence is higher than anti-HCV prevalence calculated in the same sample; 4. The prevalence of hepatitis B markers in our region is lower than in other Southern European countries.

[HCV genotypes. Liver histopathology and immunologic profile in four groups of patients]

AIM

Study on the prevalence of MCV genotypes, and correlation with liver pathology and immunological parameters.

PATIENTS AND METHODS

77 chronic hepatitis C patients (52 males, 25 females), mean age 44 +/- 14 years, belonging to four groups: (1) 23 (11 males) without other aetiology, (II) 19 (18 males) excessive drinkers, (III) 18 (12 males) haemodialysed, (IV) 17 (11 males) renal transplantation patients Genotyping was done by PCR (primers of the core, and hybridisation with specific probes). Serum Igs A, G, and M (by nephelometry), and peripheral blood lymphocyte (PBL) subsets (by flow cytometry) were determined.

RESULTS

One genotype was found in 62 patients (1b 69.2%, 1a 21.5%, 2a 3.1%, 2b 3.1%, 3a 9.2%), and two genotypes in 4 patients (1b + 3a in 1 of group 1, 1b + 2a in 2 and 1a + 3a in 1 of group 111). Twelve cases (15.6%) were not identified (NI). Relative prevalence was not different in the four groups, but in 7 drug addicts 1 b was not found (Ia in 71.4%, 3 a 28.6%) The relationship between genotypes and age was significant (p < 0.05): in the 34 patients with less than 40 years, 1b was found in 38.2%, in the others in 41.2%, and NI in 20.6%; in those with 40-60 years, 1b was found in 68.8%, in the others in 15.6%, M in 15.6%; in those above 60 years, 1b was found in 90.9%, in the others in 9.1%. Of those identified, only genotype 1 (1a and 1b) was associated to moderate or severe activity, and infected 11/13 cases of cirrhosis or severe fibrosis. IgM (g/dL) was lower in 1b than in the others: 1.58 + 1.23 vs. 2.53 + 1.93 (p < 0.01). PBL (per mm3) were lesser in 1b than in the others, with significance for the CD8+: 540t239 vs. 739 + 420 (p < 0.01).

CONCLUSIONS

Genotype 1b was the most prevalent in Portuguese patients, more significantly in the elderly, and was absent in drug addicts. The prevalence of genotypes is similar in general patients, in chronic haemodialysed, in renal transplantation recipients and in alcoholics. More severe liver pathology was associated with 1b and 1a genotypes. IgM and CD8+ had lower mean values in 1b infected patients. Other genotypes are certainly important in Portugal.

[The entire life that might have been but was not: the story of a poet with pulmonary phthisis]

In a sketch of the life history of poet Manuel Bandeira (1886-1968) from the moment his tuberculosis was diagnosed, the article analyzes the various phases Bandeira went through in his experience with the illness. Knowing that one is afflicted with a serious disease impels efforts to preserve one's identity, to adjust to living with the disease, and to mobilize resources to fight it. Living with the progression of a disease in fact prompts the afflicted individual to undertake a systematic reconstruction of his or her identity. As the article shows, poetry was the instrument Bandeira used to reshape his own self-image.

Graft versus host disease in autologous stem cell transplantation

Relapse remains the major cause of mortality in haematological malignancies treated with autologous stem cell transplantation (ASCT). Graft versus tumour reaction (GVT) associated to autologous graft versus host disease (GVDH) may contribute to eliminate minimal residual disease (MRD) after ASCT. Eighty patients with several diagnostics were submitted to ASCT. After stem cell infusion, patients randomised in 4 groups. Groups were treated as follows: Group A received either a IFN (alpha Interferon--1,000,000 U/d), Cyclosporine A (CSA--1 mg/-kg/d intravencus) for 28 days, and granulocyte-macrophage colony stimulating factor (GM-CSF-250/m2/d) until engraftment; B: CSA (same dose and way) and GM-CSF; C: CSA (1 mg/kg/d orally) and GM-CSF and D: only GM-CSF. Patients were inspected daily and if skin rash was detected, a skin biopsy was obtained at that moment, otherwise biopsies were obtained at day 21 after ASCT. GVHD was positive in 23 patients (13 from group A and 10 from group B). All cases were grades I and II. A majority of CD4+ T lymphocytes was seen in skin infiltrates. No significant differences were seen in WBC and platelets engraftment times, antibiotic administration or hospitalisation days required among the four groups. With a median follow up of 18 months, there were no differences in disease free survival (DFS) or overall survival (OS) between the patients who developed GVHD and the others. However, considering that myeloma cells do not express antigen MCH II, which is necessary for GVT effect, we excluded patients with multiple myeloma (MM) from survival analysis, thus obtaining a significant difference in OS results between patients who developed GVHD and those in whom this reaction was not observed (81% vs 58% p:0.05). We conclude that pharmacological induction of GVHD in ASCT is possible with CSA administration (1 mg/kg/d i.v.). Development of GVHD showed a better outcome for patients in our study except for those patients with MM. This results must be confirmed by a longer follow up of our patients and further studies.

Immune phenotype of chronic liver disease

Immune disorders in chronic liver disease may reflect common host propensities or disease-specific factors. Our aim was to determine the principal bases for these expressions. Four hundred fifty-one patients with various chronic liver diseases were assessed prospectively for concurrent immune disorders. Individuals with immune diseases were more frequently women (73% vs 60%, P = 0.02) and they had HLA DR4 more often than counterparts with other HLA (46% vs 23%, P = 0.000008). The association between HLA DR4 and immune disease was apparent within individual liver diseases and within different categories of liver disease. Women with HLA DR4 had a higher frequency of immune disease than women without HLA DR4 (52% vs 22%, P < or = 0.000001), and they also had immune diseases more commonly than DR4-positive men (52% vs 31%, P = 0.03). DR4-positive men, however, had higher frequencies of immune disease than DR4-negative men, especially in the nonimmune types of liver disease (26% vs 4%, P = 0.002). We conclude that HLA DR4 and female gender constitute an immune phenotype that is an important basis for autoimmune expression in chronic liver disease.

[Research in education programs]

Postgraduate medical training is intended to give competence in a specific field of medicine. Postgraduate programs should therefore be designed to offer the appropriate opportunities for the acquisition of specific knowledge and skills required for expertise in that particular medical or surgical specialty. The trained physician should not only be able to practice his specialty, but also have a deep understanding of the fundamental knowledge involved and convey this experience to others. Scientific curiosity, critical reasoning, persistence, and the ability to work in a team are important qualities that should be developed during post graduate training. Due to its requirements and methods, research clearly emerges as an important tool in promoting the timely achievement of these main objectives. All departments should be involved in basic or clinical research, and this work should be part of the postgraduate program. Finally, research activities should be appropriately valorized in the overall appreciation of the trainee's curriculum.

[Left ventricular filling in young patients with systemic lupus erythematosus in stable phase]

OBJECTIVE

The aim of this study was to evaluate the left ventricle filling pattern in patients with stable systemic lupus erythematosus (SLE).

METHODS

This prospective study was performed in 22 healthy controls and in 24 patients with stable SLE. These two groups were submitted to a clinical, electrocardiographic and echocardiographic evaluation.

RESULTS

Gender distribution and mean age were similar in both groups (p = NS). Patients with SLE were more symptomatic (21%) than control patients (0%) (p < 0.01). Left ventricular dimensions, wall thickness, and systolic function were not significantly different between the two groups. However, pericardial effusion was more frequently found in patients with SLE (21%) when compared to the control group (0%) (p < 0.05). When compared to the control group, patients with SLE showed an abnormal left ventricular filling pattern. Peak late mitral flow velocity was 0.45 +/- 0.2 m/sec in SLE patients and 0.36 +/- 0.1 m/sec in the control group (p = 0.001).

CONCLUSION

These results demonstrate that patients with stable SLE, when compared to healthy controls, are frequently associated with cardiovascular symptoms, asymptomatic pericardial effusion, and an abnormal left ventricular filling pattern.

[Sex hormones and osteoporosis: a physiological perspective for prevention and therapy]

Estrogen deficiency is the main cause of post-menopausal osteoporosis and hormone replacement therapy is consensually regarded as the first line choice for its prevention. Hormone-replacement has also been shown to prevent bone loss associated with rheumatoid arthritis (RA) and corticotherapy. The rationale for its use in RA is reinforced by evidence of beneficial effects on disease activity. Estrogens also have bone-protective effects in males. C-19 progestagens seem to potentiate the skeletal effects of estrogens whereas C-21 derivatives appear to have no significant influence. Progestagens may be particularly useful in the prevention of steroid-induced osteopenia. Testosterone is an effective treatment for male osteoporosis associated with hypogonadism and is also promising in the treatment of osteoporosis in aged eugonadal males. The association of this hormone potentiates the effects of estrogens on bone mineral density in post-menopausal women. However, anabolic androgens have been preferred in this condition, due to a lower androgenizing effect. They represent a valid therapeutic alternative, particularly in cases of cortical osteoporosis with low bone turnover and in the aged and frail. In general, the different modalities of hormonal therapy clearly deserve a higher degree of preference in the treatment and prevention of osteoporosis than common present practice in our country. It is time to reassess this matter, clear unfounded fears and reinforce the physiological and scientific foundations of our therapeutic options for osteoporosis.

Epidemiology of hepatitis C in central Portugal. Prevalence of anti-HCV in the population of the Coimbra District

Anti-hepatitis C virus antibody (anti-HCV) screening was performed in a sample of the adult population of the Coimbra District. 657 persons were included (267 male and 390 female, mean age of 42.7 + 13.1 years), aleatorily chosen from four characteristic regions. Anti-HCV was detected using an ELISA-2 test and all positive sera were also tested with RIBA-2. General prevalence of anti-HCV was 0.46%. All positive patients live in urban areas and presented risk factors for HCV infection. Anti-HCV was found in 33.3% of intravenous drug abusers, in 1.8% of transfused individuals, in 1.33% of alcoholics (higher than 80 g/d alcohol ingestion), in 1% of cases with history of surgical operations, and in 0.65% of persons who lived in risk regions for hepatitis B. We conclude that anti-HCV prevalence is low in our region. We think it is important to perform other studies on larger samples of general population and to study risk groups.

[Medical education: challenges for the future]

With the objective of contributing to the Reform of Medical Education, presently in progress in Portugal, this paper presents a short review of the main reasons to change, as well as international movements and pedagogical trends in Medical Education. Some specificities of medical education in Portugal are discussed and the main difficulties and strategies for change are addressed. The experience of the Karolinska Institute in Stockholm is reviewed and its potential correlations to the Portuguese situation are explored.

[Hepatitis C epidemiology in the central area of Portugal. Prevalence of anti-HCV in the population of the district of Coimbra]

Anti-hepatitis C virus antibody (anti-HCV) screening was performed in a sample of the adult population of the Coimbra District. 657 persons were included (267 male and 390 female, mean age of 42.7 +/- 13.1 years), aleatorily chosen from four characteristic councils. Anti-HCV was detected using an ELISA-2 test and all positive sera were also tested with RIBA-2. General prevalence of anti-HCV was 0.46%. All positive patients live in urban areas and presented risk factors for HCV infection. Anti-HCV was found in 33.3% of intravenous drug abusers, in 1.8% of transfused individuals, in 1.33% of alcoholics (higher than 80 g/d alcohol ingestion), in 1% of cases with history of surgical operations, and in 0.65% of persons who lived in risk regions for hepatitis B. We conclude that anti-HCV prevalence is low in our region. We think it is important to perform other studies in larger samples of general population and to study risk groups.

Acute abdomen caused by torsion of the pedicle in a wandering spleen

A case of acute abdomen caused by acute torsion of a wandering spleen in a 20-year-old female patient is presented. It underscores the efficiency of the ultrasonic examination in the diagnosis of this type of pathology.

[Papillary cystadenoma of the epididymis. Apropos of a rare case in a patient with grade III varicocele]

Primary tumours of the epididymis are rare and one of the rarest is papillary cysto-adenomas. For this reason, a case arising in a patient with Grade III varicocele seemed worth reporting. The report discusses the clinical case and describes the histological characteristics of the tumour.