Arterial stiffness assessment in coronary microvascular dysfunction and heart failure with preserved ejection fraction: An initial report from the WISE-CVD continuation study

Background

Heart failure with preserved ejection fraction (HFpEF) is the most common cardiac complication in patients with coronary microvascular dysfunction (CMD), yet its underlying pathways remain unclear. Aortic pulse-wave velocity (aPWV) is an indicator of large artery stiffness and a predictor for cardiovascular disease. However, aPWV in CMD and HFpEF is not well characterized and may provide understanding of disease progression.

Methods

Among participants without obstructive coronary artery disease, we evaluated 51 women with suspected CMD and 20 women and men with evidence of HFpEF. All participants underwent aPWV measurement (SphygmoCor, Atcor Medical) with higher aPWV indicating greater vascular stiffness. Cardiac magnetic resonance imaging (CMRI) assessed left ventricular (LV) ejection fraction, CMD via myocardial perfusion reserve index (MPRI), and ventricular remodeling via LV mass-volume ratio. . Statistical analysis was performed using Wilcoxon rank sum tests, Pearson correlations and linear regression analysis.

Results

Compared to the suspected CMD group, the HFpEF participants were older (65 ± 12 vs 56 ± 11 yrs., p = 0.002) had higher BMI (31.0 ± 4.3 vs 27.8 ± 6.7 kg/m2, p = 0.013), higher aPWV (10.5 ± 2.0 vs 8.0 ± 1.6 m/s, p = 0.05) and lower MPRI (1.5 ± 0.3 vs1.8 ± 0.3, p = 0.02), but not remodeling. In a model adjusted for cardiovascular risk factors, the HFpEF group had a lower LVEF (estimate -4.78, p = 0.0437) than the suspected CMD group.

Conclusions

HFpEF participants exhibit greater arterial stiffness and lower myocardial perfusion reserve, with lower LVEF albeit not remodeling, compared to suspected CMD participants. These findings suggest arterial stiffness may contribute to progression from CMD to HFpEF. Prospective work is needed and ongoing.

Coronary atheroma burden predicts flow reserve in women with ischemia and nonobstructive coronary artery disease

Background

Women with signs and symptoms of ischemia and no obstructive coronary artery disease often have coronary microvascular dysfunction (CMD) with reduced coronary flow reserve (CFR), and compensatory coronary remodeling. Angiographic measurements of epicardial coronary anatomy (AMCA) may improve understanding of relations between CFR and atherosclerosis. We investigated AMCA and CFR in women evaluated for CMD.

Methods

Women consecutively enrolled in the Women's Ischemia Syndrome Evaluation CVD Continuation (NCT00832702) were included. All underwent clinically indicated coronary function testing measuring CFR. AMCA included coronary angiographic atheroma burden (AB), percent diameter stenosis (PDS), and tapering reference diameter Z score (RDZ), derived for the left main and left anterior descending coronary epicardial segments.

Results

The 51 women were aged 55.8 ± 10.8 years, with 19(38%) hypertensive, 10(20.4%) hyperlipidemic, 4(7.8%) diabetic, 13(25.5%) prior smokers, and mean CFR 3.0 ± 0.8. Both average and maximal AB negatively correlated with CFR (r = -0.30 and -0.31, with p = 0.04 for both), as did average and maximal PDS (r = -0.38 and -0.41 with p = 0.009 and p = 0.005) while average RDZ was directly related (r = 0.37, p = 0.01). Multiple linear regression analyses revealed that both average PDS (Units of CFR -0.03 95% CI: -0.06, -0.002, p = 0.023) and maximal PDS (-0.04 95% CI -0.07, -0.01, p = 0.007) were negatively related to CFR.

Conclusions

Measures of epicardial coronary atheroma burden, size and tapering are related to CFR, suggesting that atherosclerotic anatomical findings may contribute to or be a consequence of CMD, with further work is needed to investigate these measures as treatment targets.

Influence of Ischemia Time in Injury of Deep Peribiliary Glands of the Bile Ducts Graft: A Prospective Study

The deep peribiliary glands (DPBG) are a niche of progenitor cells in the wall of the biliary duct (BD) and are the second line of multiplication when severe lesion of the epithelium occurs. Previous studies have identified DPBG injury as a cause of post-liver transplant (LT) biliary stenosis; this complication is a major cause of post-LT morbidity. The incidence of biliary stenosis in our center is high (38.1%). This study evaluates the lesion of DPBG in response to ischemia. Graft BD was collected in adult LT between August 2016-July 2017, from donation after brain death. Samples of 45 grafts were collected at 2 moments: BD1-during graft preparation and BD2-before biliary anastomosis. Histological analysis of the samples was performed and then classified according to degree of lesion (0, ≤50%, and >50%). A comparison was made between the degree of lesion and graft ischemia, graft histology, donor, and procurement variables. The DPBG lesion was more frequent in BD2 (20.9% vs 7%, P = .079). BD2 lesions with DPBG lesions had higher medians and means at all times of ischemia. The difference was greater in the warm ischemia time (0: 43.3 ± 12.53 minutes vs ≤50%: 52.4 ± 14.38 minutes, P = .068). The group of BD1 with DPBG lesion presented superior median cold ischemia time (CIT). In the analysis of the remaining variables there were also no statistically significant differences. We concluded that during the period of CIT there is already lesion of the DPBG, which increases after reperfusion of the graft, in greater association with longer warm ischemia time.

Induction of M2 Macrophages Prevents Bone Loss in Murine Periodontitis Models

Periodontitis is characterized by the progressive destruction of tooth-supporting alveolar bone, which is mainly caused by chronic inflammation in response to persistent bacterial insult. It has recently become clear that the pathogenesis of periodontitis is associated with a high ratio of proinflammatory M1 (classically activated) macrophages to anti-inflammatory M2 (alternatively activated). To decrease the inflammatory activity, we locally delivered the C-C motif chemokine ligand 2 (CCL2) using controlled-release microparticles (MPs). CCL2 is known to promote chemotaxis of M0 or M2 phenotype macrophages to the inflamed site and induce M2 phenotype polarization locally. Our in vitro data showed that CCL2 increased the number of M2 phenotype macrophages, decreased TNF-α secretion, and enhanced chemotaxis of RAW264.7 cells toward CCL2 MPs. Moreover, we induced periodontal disease in 2 animal models through inoculation of Porphyromonas gingivalis and ligature around the murine molar. Micro-computed tomography analysis showed significant reduction of alveolar bone loss in the CCL2 MP treatment group when compared with a blank MP group and a no-treatment periodontitis group in both models. Immunohistologic analysis showed a significant increase in the M2 phenotype subset and a decrease in the M1 phenotype subset in the CCL2 MP group of the P. gingivalis-induced model. Also, in both models, tartrate-resistant acidic phosphatase staining showed significantly fewer numbers of osteoclasts in the CCL2 MP group in alveolar bone area. Moreover, quantitative polymerase chain reaction results showed a significant increase in IL-1RA (interleukin 1 receptor antagonist) mRNA expression and a decrease in RANKL (receptor activator of nuclear factor kappa-Β ligand) mRNA expression in the CCL2 MP group in the ligature model. In summary, manipulation of endogenous M2 phenotype macrophages with CCL2 MPs decreased the M1 phenotype:M2 phenotype ratio and prevented alveolar bone loss in mouse periodontitis models. The delivery of CCL2 MPs provides a novel approach to treat periodontal disease.

CA 549 and SP2 in postoperative breast cancer patients. Comparison with CA 15.3, CEA and TPA

The levels of CA 549 and SP2 were measured in 430 subjects: 100 healthy blood donors, 130 patients with benign diseases and 200 postoperative breast cancer patients. In the latter group, the serum levels of CA 15.3, CEA and TPA were also measured. The Kolmogorov-Smirnov, Mann Whitney and McNemar tests were used for statistical analysis. The upper normal limits were established on the basis of the values obtained in the healthy blood donors group, the benign diseases group and R.O.C. analysis of the breast cancer group. They were: CA 549 = 13 U/ml, SP2 = 14 U/ml, CA 15.3 = 35 U/ml, CEA = 5 ng/ml and TPA = 110 U/ml. The sensitivity, specificity and accuracy in the breast cancer group were, respectively: CA 549 = 78.1%, 97.1% and 88%; SP2 = 21.9%, 90.4% and 57.5%; CEA = 66.7%, 95.2% and 81.5%; CA 15.3 = 80.2%, 98.1% and 89.5%, and TPA = 73.9%, 78.8% and 76.5%. Statistical analysis showed significant differences only between CA 15.3, the marker which gave the best results, and SP2 (p<0.001). There were no significant differences with the association of two or three tumor markers.

Evidence-based guides in tracheostomy use in critical patients

OBJECTIVES

Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research.

METHODS

A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions.

CONCLUSION

Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

Abstract P1-07-18: Breast cancer in young patients, twelve years of experience in a single institution

Breast cancer is very rare in young women and has a more aggressive biological behavior and a worse prognosis than in older premenopausal women. This study was designed to determine and evaluate the features of breast cancer in young patients less than 35 years old at the Instituto Nacional de Enfermedades Neoplásicas, Lima - Perú.

Medical records of 115 patients less than 35 years old with breast cancer, whom were diagnosed and received a kind of treatment, even surgery, chemotherapy, radiotherapy or all of them at the Instituto Nacional de Enfermedades Neoplásicas Lima-Perú, between January 2000 and December 2012, were reviewed.

Triple negative breast cancer (38.3%) is the most common subtype cancer and its presentation is in a lower age compared with the others subtypes (27.1 years vs 28.5 years p: 0.047). The high histological grade was more frequent in triple negative and HER2 subtypes (80% both vs 30% and 48% for luminal A and luminal B p: 0.001). The 2 yr and 5 yr overall survival was 75.0% and 59.3% for luminal A, 71.4% and 55.1% luminal B, 67.7% and 54.9% triple negative, 58.3% and 41.7% HER2 (p: 0.434). The 2 yr progression free survival was 81.6%, 72.6%, 61.5% and 59.4% for each group respectively (p: 0.522).

As conclusion, the breast cancer in 35 yr old or less women is uncommon; the triple negative subtype is more common, also in relation with high histological grade and in lower age. The overall survival and the progression free survival are worse in patients with lower age.

Citation Format: Morante ZD, Pacheco C, Limón RS, Neciosup S, Gomez HL. Breast cancer in young patients, twelve years of experience in a single institution. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-07-18.

The influence of fish culture in floating net cages on microbial indicators of water quality

This work was carried out to analyse the microbiological parameters of the water quality of a reservoir used for the irrigation and culture of tilapia (Oreochromis niloticus) in floating net cages. The physico-chemical parameters, counts of mesophilic total aerobic bacteria, total and thermotolerant coliforms and fecal streptococci, and the presence of Escherichia coli in samples of water collected in three sites of the reservoir (pre-culture site, culture site, post-culture site) were analysed. The levels of ammonia (0.047-0.059 mg/L), nitrite (0.001-0.021 mg/L) and total phosphorus (0.050-0.355 mg/L) in the water did not show significant differences (p > 0.05) between sampling sites. The levels of total bacteria in the water varied between 1.3 x 10(4) and 67.3 x 10(4) CFU/100 mL. The MPN values of thermotolerant coliforms (< 930 MPN/100 mL) were within values recommended for water used for fish culture and/or irrigation. The presence of E. coli and fecal streptococci were verified in 48% and 56% of analysed samples, respectively. The site with floating net cages showed more samples contaminated with E. coli and fecal streptococci than other sampling points.

Chronic granulomatous disease associated with common variable immunodeficiency - 2 clinical cases

INTRODUCTION

Chronic granulomatous disease associated with common variable immunodeficiency (GD-CVID), although well documented, is rare. Granulomatous lesions can affect several organs and are histologically indistinguishable from sarcoidosis.

CLINICAL CASES

Case 1: A 39-year-old male patient with CVID, asymptomatic although with thrombocytopenia and mediastinal-hilar adenopathies. GD-CVID was diagnosed by bone marrow biopsy. Progressive clinical and radiological improvement was obtained with corticotherapy. Case 2: A 38-year-old male patient with CVID, suffered from asthenia, anorexia, myalgia, lower limbs edemas, and dry cough. He had mediastinal and bilateral hilar adenopathies within which biopsy revealed non-necrotizing granulomatous infiltrate. A spontaneous resolution was detected after 9 months of evolution.

CONCLUSION

GD-CVID is rare and can mimetize other pathologies, namely, sarcoidosis; it should therefore be publicized and discussed so that it becomes a general clinical knowledge.

Patient- and physician-level determinants of blood pressure response to treatment in normal weight and overweight patients (the PREVIEW study)

BACKGROUND AND AIMS

Obesity combined with hypertension places patients at greater risk for target-organ damage and cardiovascular disease. The purpose of this secondary analysis was to identify physician- and patient-levels determinants of blood pressure (BP) values and predictors of uncontrolled BP through subgroup analysis by body mass index (BMI).

METHODS AND RESULTS

We conducted a subgroup analysis of 3006 patients with High-BMI (BMI >25 kg/m(2); n=2124) and Normal-BMI (BMI<25 kg/m(2); n=882) treated by 504 physicians and enrolled in PREVIEW, a Belgian prospective, multi-center, pharmaco-epidemiological study of 90-day second-line treatment with valsartan. Physician- and patient-level determinants of BP values and BP control were identified by means of hierarchical linear and logistic regression. Blood pressure values and control after 90 days of treatment were consistently lower for the High-BMI group. The 25.5% of variance in 90-day systolic and 28.3% of the variance in 90-day diastolic BP were attributable to physician-level determinants for the High-BMI group; versus 27.3% and 29.8% for the Normal-BMI group (ICC=0.273 and 0.298, respectively). Determinants of 90-day BP values and predictors of uncontrolled BP varied considerably by BMI status.

CONCLUSION

Several common and unique patient- and physician-level determinants of BP values and control were identified for the High-BMI and Normal-BMI groups. These findings highlight the need for differentiating healthcare interventions to account for patient and physician variables, particularly with respect to effective BP management in vulnerable populations.

An extracellular mechanism that can explain the neurotoxic effects of α-synuclein aggregates in the brain

Neurodegenerative diseases, such as Parkinson's disease (PD), Alzheimer's disease (AD), and Dementia with Lewy bodies (DLB), display an accumulation of proteins including α-synuclein aggregates in cortical and subcortical regions of the brain. PD is a complex, progressive disease which involves damage of motor and cognitive brain regions, as well as autonomic and sensory areas. Since α-synuclein is a neuronal cytosolic protein, it is assumed that pathogenic changes induced by α-synuclein aggregates occur only at the cytoplasmic level. However, recent studies have identified the presence of extracellular α-synuclein, suggesting that the pathogenic action of this protein may also occur in the extracellular milieu through an unknown mechanism. One of the hypotheses is that extracellular α-synuclein aggregates or oligomers may directly disrupt the neuronal membrane by the formation of a pore reminiscent to the ones formed by β-amyloid aggregates. Here, we will review some evidence that support this mechanism, analyzing the interactions of α-synuclein with components of the plasma membrane, the formation of pore/perforated structures, and the implications on ionic dyshomeostasis. Furthermore, we will also discuss how this mechanism can be integrated into a general phenomenon that may explain the synaptotoxicity and neurotoxicity observed in different neurodegenerative diseases.

[Multifocal epithelioid angiosarcoma of bone with lung metastases]

Angiosarcoma is a rare mesenchymal neoplasm that may arise from vascular or lymphatic tissue. Bone primary angiosarcoma is extremely rare, representing less than 1% of all angiosarcomas. It́s a very aggressive neoplasm and patients have metastatic disease at initial diagnosis in a large percentage of cases. On radiographs, these lesions are usually aggressive osteolytic lesions, commonly with soft-tissue mass extension, and tumoral enhancement on CT or MR imaging. The appearance of the bone scan is variable, describing studies with tracer uptake or low uptake. These tumours are more often found in the long bones, but spinal involvement has been reported in 10% of patients. There are a few reports in the literature of bone angiosarcoma with lung metastases. We present a patient with multifocal epithelioid angiosarcoma (spine and ribs) and multiple lung metastasis, evidenced by CT and conventional bone scintigraphy, with a fast growth.

Quality of care in longer term mental health institutions in Portugal

Introduction

Deinstitutionalisation of the mentally ill is an ongoing process in European countries. Quality of care in residential facilities, however, was seldom assessed in part due to the lack of adequate instruments.

Objectives

To assess the quality of care in Portuguese residential facilities for long term mental patients.

Methods

Quality of care in residential facilities was assessed with the toolkit developed by the DEMoBinc study using interviews with the units’ managers, and the users.

Results

The 20 units assessed across Portugal were mainly located in the city; 13 were in a hospital setting and 7 in the community. Most of the units (90%) had no maximum length of stay, and 60% were mixed-gender; 85% of the users were not compulsory. Most of the units (60%) had no one-bedrooms, and their aim was rehabilitative in 40%, and rehabilitative plus providing support in 40%. The rate of patients with a bank account was 49.4%, 32.4% were in charge of their finances, while only 14.1% had voted.

In hospital vs. community units patients were more frequently men (80.5 vs. 53.8%) and older (51.1 ± 13.7 vs. 43.3 ± 9.6, p < .001). In community units the treatment was more frequently explained (50 vs. 26.3%), patients’ involvement was higher (40.4 vs. 19.5%), while mean GAF scores (64.9 vs. 60.2) did not differ.

Conclusions

Portuguese results show that in spite of the effort to create new facilities for the longer term mentally ill, a lot still has to be done to improve the quality of care they provide.

[Monitoring cognitive characteristics in a population with hereditary cerebrovascular disease (CADASIL) in Colombia]

INTRODUCTION

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a hereditary disease that affects small vessels and presents with vascular episodes, neuropsychiatric disorders, migraine and cognitive impairment. The cognitive disorder varies according to the time elapsed since onset. It is a condition with a subcortical origin related to executive dysfunction, slowing, attention-related disorders and memory disorders.

AIM

To define the cognitive characteristics in two neuropsychological evaluations of carriers of Notch3 gene mutations as compared to non-carriers belonging to Colombian families with CADASIL.

SUBJECTS AND METHODS

The study followed a longitudinal, retrospective design with 140 participants, including both carriers and non-carriers of the mutation. Cognitive performance was analysed by comparing the first and the last neuropsychological evaluation carried out on each subject at a four-year interval.

RESULTS

There were statistically significant differences (p < 0.05) between the two groups in the last evaluation, but only in some tests. Carriers and non-carriers did not display any significant changes between the first and the last evaluation.

CONCLUSIONS

No differences were found between both groups in the two evaluations. Cognitive impairment is not observed with the passage of time in carriers, probably owing to the fact that most of them were young, asymptomatic subjects. We believe that four years' follow-up is not enough time to observe a significant progression in the alterations affecting the cognitive functions in carriers of mutations in the Notch3 gene, which causes CADASIL. We also consider that more sensitive cognitive tools are needed to perform the neuropsychological evaluation.

Larval Pacific herring, Clupea pallasii (Valenciennes), are highly susceptible to viral haemorrhagic septicaemia and survivors are partially protected after their metamorphosis to juveniles

Pacific herring were susceptible to waterborne challenge with viral haemorrhagic septicaemia virus (VHSV) throughout their early life history stages, with significantly greater cumulative mortalities occurring among VHSV-exposed groups of 9-, 44-, 54- and 76-day-old larvae than among respective control groups. Similarly, among 89-day-1-year-old and 1+year old post-metamorphosed juveniles, cumulative mortality was significantly greater in VHSV-challenged groups than in respective control groups. Larval exposure to VHSV conferred partial protection to the survivors after their metamorphosis to juveniles as shown by significantly less cumulative mortalities among juvenile groups that survived a VHS epidemic as larvae than among groups that were previously naïve to VHSV. Magnitude of the protection, measured as relative per cent survival, was a direct function of larval age at first exposure and was probably a reflection of gradual developmental onset of immunocompetence. These results indicate the potential for easily overlooked VHS epizootics among wild larvae in regions where the virus is endemic and emphasize the importance of early life history stages of marine fish in influencing the ecological disease processes.

Treatment for children with severe aplastic anemia and sickle cell disease in low income countries in Latin America: a report on the recent meetings of the Monza International School of Pediatric Hematology/Oncology (MISPHO): Part III

Treatment of hematologic disorders in low-income countries (LIC) is difficult. This report summarizes treatment of sickle cell disease and aplastic anemia by pediatric hematologists from 15 LIC who participate in the Monza International School of Pediatric Hematology/Oncology (MISPHO). Patients with severe sickle cell disease were treated with low dose hydroxyurea, which safely reduced vaso-occlusive crises. Patients with severe aplastic anemia fared poorly due to lack of availability and high cost of anti-thymocyte globulin and cyclosporine and lack of access to stem cell transplantation. Appropriate therapy was most likely to occur in MISPHO centers with an active twinning program with a center in a high-income country.

Long-term safety and tolerability of tadalafil in the treatment of erectile dysfunction

OBJECTIVE

To assess the long-term safety and tolerability of tadalafil for patients with erectile dysfunction (ED).

PATIENTS AND METHODS

This was a multicentre, open-label, 24-month extension trial involving 1173 men with ED. The mean age was 57 (range 23-83) years and 74.8% of patients were taking concomitant medications for comorbid conditions, including diabetes mellitus in 30.5% of men and hypertension in 29.5%. These patients had participated in 1 of 5 previous 8-week or 12-week randomised, double-blind, placebo-controlled tadalafil studies. In the present trial, the starting 10mg dose of tadalafil could be increased to 20mg if the patient could not achieve satisfactory intercourse or reduced to 5mg for an adverse event that was persistent, intolerable and judged by the investigator to be related to tadalafil.

RESULTS

Four hundred ninety-three (42.0%) men completed 24 months of treatment. In addition, a further 234 (19.9%) completed 18 months of treatment due to a sponsor decision to reduce the study duration. The total tadalafil exposure was 1676.0 patient-years. Tadalafil was safe and well tolerated. Headache (15.8%), dyspepsia (11.8%), nasopharyngitis (11.4%), and back pain (8.2%) were the most common treatment-emergent adverse events. The rate of discontinuations due to adverse events for this 18-24-month study was 6.3% and the rate for any individual event was <1%. Serious adverse events occurred in 8.6% of patients. No consistent pattern of serious adverse events assessed as causally associated with tadalafil administration was observed. None of the four deaths that occurred during the study was assessed as tadalafil related. There were no clinically significant laboratory or electrocardiographic findings or changes in vital signs in mean baseline-to-endpoint analysis attributable to tadalafil. Tadalafil administration was not causally associated with drug-induced hepatotoxicity, neutropenia, thrombocytopenia, or renal dysfunction.

CONCLUSION

Tadalafil at doses of 5, 10, or 20mg taken as needed up to once daily for 18 to 24 months was safe and well tolerated. These findings support the long-term use of tadalafil in the clinical management of erectile dysfunction.

Clinical epidemiology of childhood cancer in Central America and Caribbean countries

BACKGROUND

Countries with scarce resources have the right to appropriate essential health care but very few reports discuss how this can be achieved. We assessed the survival of a large cohort of pediatric oncological patients to provide hard data on which to base realistic evaluation and planning schemes.

PATIENTS AND METHODS

This multicenter retrospective survey covered consecutively diagnosed and treated patients admitted to eight national level hospitals in seven countries in Central America and the Caribbean. The research protocol was discussed extensively, so the data to be collected and the criteria for their evaluation were clearly pre-defined. We analysed 2214 patients diagnosed between 1996 and 1999 with various cancers, classified as hemato-oncological disorders (70%) and solid tumors (30%).

RESULTS

Three-year overall survival was 48.4% [standard error (SE) 1.3]. Detailed analysis of acute lymphoblastic leukemia highlighted the wide intercountry variability: 3-year survival was 62.2% (SE 5.3) in Cuba, 74.2% (SE 3.3) in Costa Rica, 61.7% (SE 4.9) in Nicaragua, and lower in the other four countries.

CONCLUSIONS

The yield of diagnostic-therapeutic protocols depends largely on the context of care in which they are applied. This paper documents the importance of including epidemiological research in interventions for cooperation in complex health areas such as pediatric oncology.

Cerebrospinal fluid S-100 protein levels in neurological pathologies

The aim of this paper was to evaluate S-100 concentration in cerebrospinal fluid (CSF) from patients with different neurological disorders, and in subjects with no proven neurological pathology, in order to study possible differences in their protein concentrations. The total number of patient-samples examined was 119 (58 males and 61 females; mean age 35 yrs, 1-79 yrs). Based on the final diagnoses, nine patient groups were studied: a control group, meningitis, acute lymphatic leukemia (ALL), dementia, hydrocephalia, polyneuropathy-motor neuron disease, acute cerebral infarction (ACI), and patients diagnosed with multiple sclerosis. S-100 protein concentrations were measured by the Sangtec 100 two-site immunoradiometric assay. The highest S-100 levels in CSF were found in the dementia group, ACI group, bacterial-fungal and lymphocytic meningitis groups (Kruskal-Wallis test). The S-100 concentrations in these groups were significantly higher compared with the control group (Mann-Whitney U test, p<0.05, p<0.01) and the multiple sclerosis group (p<0.05, p<0.01). No other significant differences were found between groups. Our results suggest that the high protein levels in CSF found in these pathologies may reflect the presence of brain damage. However, the levels need to be considered individually, as they depend on several factors, such as age, severity of brain damage or interval between the onset of brain damage and the taking of the sample.

[Level of S-100 and neuron-specific enolase in cerebrospinal fluid from subjects with neurological pathologies]

AIM

To evaluate S-100 and neuro specific enolase (NSE) levels in cerebrospinal fluid (CSF) from patients with differents neurological disorders in order to study possible differences in their protein concentrations.

MATERIAL AND METHODS

We analysed samples of CSF taked by spinal puncture in subjects either from of the Casualty Department or from the Department of Neurology. Patients displaying neurological symptoms capable of being diagnostically tested. The total number of patients-samples examined was 43 (23 males and 20 females; mean age 43 y, range 1-78 y). Five patients groups were studied: a control group, meningitis, dementia, polyneuropathy-motorneuron disease, and acute cerebral infarction group (ACV). S-100 and NSE concentrations were measured by immunoradiometric procedures.

RESULTS

Highest S-100 median levels in CSF were found in dementia and ACV group, with elevate concentrations in meningitis groups. The increased S-100 levels in these groups was significant compared with control group (Mann-Withney U test). For NSE concentrations, there is a significant differences between dementia group and control group. No other significant differences were found between groups. There were positive correlation between S-100 levels and total protein.

CONCLUSION

Our results suggest that S-100 and NSE can be a sensitive marker of brain damage in different neurological disorders. However, levels must be considered individually, since these concentrations depend on several factors, such as age, severity of brain damage or interval between the onset of brain damage and the taking of the sample.

[Pulmonary activity in sarcoidosis: 67Ga uptake quantification and plasma determination of 1,25-dihydroxyvitamin D)]

AIM

The aim of our study was to produce a quantitative determination of Ga-67 pulmonary intake and correlate it with plasma levels of calcitriol.

MATERIAL AND METHODS

A prospective study was conducted, and included 65 patients (29 female, 36 male) referred to our section due to suspected sarcoidosis or fibrosis of the lungs. Gammagraphic images were obtained after injecting Ga-67 citrate, and vitamin D was determined by IRMA method. The final diagnosis led to 4 groups of patients: 26 with active sarcoidosis; 5 with inactive sarcoidosis (4 with a previous gammagraphic study, included in the previous group); 8 with fibrosis of the lungs; and 30 patients with no demonstrable pathology following medical/instrumental examination. For the quantitative analysis, areas of interest were drawn around each lung, together with another region in soft tissue of the right shoulder (background). The geometric mean for each region was calculated, as well as the Ga intake rate (InGa = [lung activity-background]/background).

RESULTS

Significant differences were found (p<0.01) when comparing each group's InGa, with the highest values occurring in the active sarcoidosis group. No significant differences were found when comparing plasma levels of calcitriol. No significant correlation was demonstrated between hormone and InGa rates.

CONCLUSIONS

InGa would seem to be a useful parameter for assessing inflammatory activity in the parenchyma of the lungs. Perhaps as a result of their variability, plasma concentrations of the active vitamin D metabolite have a limited role in this assessment.

Treatment of childhood Wilms' tumor without radiotherapy in Nicaragua

BACKGROUND

Recent trends in therapeutic strategies for Wilms' tumor are based on an attempt to reduce or omit radiotherapy (RT) in a sizable fraction of patients. We report here the clinical and histological features as well as the results obtained in 37 children (23 males, 14 females; median age at diagnosis 3 years, range 0.8-8 years) diagnosed between 1991 and 1996, and treated with chemotherapy (CT) and surgery at La Mascota Hospital, Managua, Nicaragua.

PATIENTS AND METHODS

Patients were grouped as follows: those who underwent surgery at diagnosis (group A, n = 4), patients who received preoperative CT because of large tumor size (group B, n = 27), lung metastases (n = 5) or bilateral disease (n = 1) (group C, n = 6). Treatment consisted of vincristine (VCR) and actinomycin-D (ACTD) for 24 weeks in group A, and of VCR, ACTD and adriamycin for 68 weeks in groups B and C. Histology was classified as favorable in 30 patients (81%), unfavorable in six patients (all of group B) and unknown in one.

RESULTS

With a median follow-up time of 6.4 years the event-free survival for the whole group was 80.1%+/-6.8 (SE). No event occurred beyond 5 years of diagnosis.

CONCLUSIONS

These results suggest that RT does not appear necessary for the majority of patients, and that an excellent surgical approach associated with an intensive CT schedule can control the disease, even in the absence of adequate information on the intra-abdominal tumor extent.

[Effect of different observers on the interpretation of pulmonary perfusion scintigraphy]

AIM

The agreement in the interpretation of the scintigraphic images of pulmonary perfusion in the diagnosis of pulmonary tromboembolism (TEP) is not always the most adequate. The purpose of this study was to evaluate the degree of agreement by eight observers in the interpretation of these studies.

MATERIAL AND METHODS

The study population consisted of 180 studies with clinically suspected pulmonary embolism referred to our department for scintigraphic perfusion imaging from April 98 to September 99. The patients received an intravenous injection of 111-148 MBq (3-4 mCi) of 99mTc-macroaggregated albumin whereas the images were obtained in the six routine projections. The observers consisted of five nuclear medicine physicians and three residents who independently reviewed the scintigrams (low, intermediate and high probability). In a second step, the physicians performed consensus interpretations. The Kappa statistics was used to evaluate the degree of agreement between individual observer interpretations beyond that expected by chance alone.

RESULTS

The mean value SEM for Kappa index was 0.58 0.02, with maximum and minimum values of 0.76 and 0.27 respectively. The interobserver variability was greater than expected. Except in two observers scans in the interpretation of images in the low and high categories showed minor discrepancies, whereas scans in intermediate probability showed the most important interobserver variations.

CONCLUSION

The study manifests the importance of a uniform criteria in lung scintigraphic interpretation.

Evaluation of headache intensity in migrainous patients with visual handicap through the tactile analogical scale (TAS)

The tactile analogue scale (TAS) was elaborated to be used in blind subjects or those who can not use the vision during their crises. The objective of this study was to characterize, from TAS, the architecture of migraine attacks in subjects with visual disability. For that, 11 migrainous with visual disturb (MVD) subjects were studied and 22 migrainous subjects with no visual disability as a control group. All patients fulfilled the criteria for migraine and the patients of the group studied showed visual acuteness less than 20/200. To evaluate the results, the patients of the group MVD were subdivide within two groups, according to their visual acuteness: subgroup A subjects with subnormal vision and subgroup B amaurotic ones. In subgroup A measurement 46 attacks with average of the migraine attacks of the 56.50 mm, in the subgroup B 45 attacks with average of the 59.58 mm and in the control group 92 attacks with average of the 49.88 mm. When subgroup B and control group were compared there was a significant statistic difference (p=0.022). Through these outcomes we can observe that the migrainous subjects with no visual afference show a higher pain intensity during the migraine crises comparing to those subjects with no visual handicap. The study suggests that, as in other forms of sensibility, the total visual loss can also interfere in the nociceptive control of the pain during the migraine attacks.

[Comparative study of coronary angioplasty in diabetic patients. Immediate clinical and angiographic results and clinical evolution in the first year of follow up]

BACKGROUND

The success of revascularization procedures for coronary artery disease could be lower in diabetic patients.

AIM

To report the results of coronary angioplasty in diabetic and non diabetic patients.

PATIENTS AND METHODS

All angioplasty procedures performed between 1996 and 1999 were recorded. Demographic data, procedure details, hospital outcome and evolution at one year of follow up were analyzed.

RESULTS

During the study period, 358 patients were treated; of these, 79 were diabetics. Despite the greater severity of coronary lesions among diabetic patients the clinical success of the procedure was 92.4% in diabetics and 91.8% in non diabetics. Hospital mortality was 1.3% in diabetics and 0.7% in non diabetics. Major complications occurred in 3.8% of diabetics and 3.2% in non diabetics. One year survival was 95.9% for diabetics and 98% in non diabetics. There were five late cardiac deaths among non diabetics and 3 among diabetics during the year of follow up. The frequency of new revascularization procedures was 4.3% in diabetics and 8.3% in non diabetics. Event-free survival was 95.6% in diabetics and 89.2% in non diabetics.

CONCLUSIONS

Results of angioplasty were similar in diabetic and non diabetic patients in terms of hospital outcome and late follow-up.

Early detection of maedi-visna (ovine progressive pneumonia) virus seroconversion in field sheep samples

The aim of this work was to investigate whether an enzyme-linked immunosorbent assay (ELISA) was useful for early detection of maedi-visna virus (MVV) infection in sheep under field conditions. An ELISA based on p25 recombinant protein and a gp46 synthetic peptide was used. Sequentially obtained serum samples (n = 1,941) were studied for 4 years. ELISA results were compared with those of the agar gel immunodiffusion (AGID) test, and results of both tests were compared with a reference result established using consensus scores for at least 2 of 3 serologic techniques (AGID, ELISA, and western blotting, which was used to resolve result discrepancies between the other 2 techniques). A total of 247 discrepancies were observed between ELISA and AGID. Of these, 131 were due to an earlier detection of 120 sera by the ELISA and 11 sera by AGID. The remaining discrepancies (116) were due to the presence of false reactions in both tests. Fewer false-negative results were found by ELISA than with AGID (6 vs. 69 sera, respectively), whereas the number of false-positive results was virtually the same for ELISA and AGID (21 vs. 20, respectively). In relation to the reference result, ELISA sensitivity and specificity were 97.8% and 98.2%, respectively, whereas values for AGID were 76.3% and 98.3%, respectively. The agreement between ELISA and the reference result was higher than that between AGID and the reference result (K value: 0.96 and 0.77, respectively). A variation in the ELISA signal (based on optical density) was observed during the study period, suggesting different antibody levels throughout the animal's life. The ELISA was useful for detecting MVV-infected sheep in field conditions and has potential for use in control and eradication programs.

[Prevalence and semiologic aspects of the idiopathic stabbing headache in a migraine population]

Idiopathic stabbing headache is a quite unknown disorder. Its main features consist of brief stabbing pains, lasting few seconds. In most cases, idiopathic stabbing headache is underdiagnosed. We have followed up migraine patients during a period of 12 months, aiming to determine the prevalence and main features of idiopathic stabbing headache while occurring apart from migraine attacks. Two hundred and thirty-three of the 280 patients initially surveyed were included in the analysis of the results. Ninety-four patients presented idiopathic stabbing headaches (40.4%), being 72 of them females (76.5%). For migraine with idiopathic stabbing headaches, mean age, age of beginning of migraine and years with migraine were 33, 22.5 and 10.6 years, respectively. Mean duration of the idiopathic stabbing headaches was reported to be 1.42 seconds [ 1 second by 68 patients (72.4%), 2 seconds by 17 (18.1%), 3 seconds by 6 (6.3%), 4 seconds by 1 (1.05%) and 5 seconds by 2 (2.15%)]. Pain paroxysms were reported to be unilateral by 86 (91.4%) and bilateral by 8 (8.6%) of the cases. They were reported to be temporal by 56 patients (60%), occipital by 15 (15.6%), frontal by 8 (8.5%), temporo-occipital by 7 (7.4%), parietal by 5 (5.3%), fronto-temporal by 1 (1.06%), cervical by 1 (1.06%) and ocular by 1 patient (1.06%). The study confirms a high prevalence of idiopathic stabbing headaches in migraineurs. Its main clinical features could be well determined during the interval between migraine attacks.

[The classification of coronary lesion from Society for Cardiac Angiography and Intervention predicts better results of coronary angioplasty than the one from American College of Cardiology/American Heart Association Coronary Disease]

BACKGROUND

The classification of coronary lesion complexity, using the American College of Cardiology/American Heart Association (ACC/AHA) is a predictor of balloon angioplasty success. Stents have improved results even in complex lesions.

AIM

To compare the ACC/AHA and the new Society for Cardiac Angiography (SCA&I) coronary lesion scores as predictors of angioplasty success.

PATIENTS AND METHODS

Ali consecutive angioplasty procedures (n = 346, 456 lesions, 47% stents) were prospectively analyzed from August 1996 to March 1999. Coronary lesions were classified using the ACC/AHA and SCA&I scores. Angiographic success was assessed and its multivariate predictors determined with logistic regression analysis.

RESULTS

According to the ACC/AHA score, angiographic success was 97, 92.7, 93.3, and 82.3% in A, Bl, B2 and C lesions respectively (p = 0.013). There only were significant differences in success between C and A, Bl or B2 lesions. According to the SCA&I score success was achieved in 97.3, 97.9, 75.8 and 33.3% in nonCP, CP, nonCO and CO lesions respectively (P < 0.001). With the SCA&I score statistically significant differences in angiographic success were found for all lesion score comparisons, except between nonCP and CP lesions. No other variables had predictive value for angiographic success.

CONCLUSIONS

Coronary angioplasty angiographic success is better predicted by the new SCA&l lesion score than with the ACC/AHA lesion classification in a group of patients with frequent use of stents.

[Using algometry of pressure measuring the threshold of trigeminal pain perception in normal volunteers: a new protocol of studies]

Algometry of pressure is a technique that measures the physiology of the nociceptive system. Acting directly on the responsive peripheral nociceptors to pressure stimuli, this technique allows the study on nociceptive integrity in normal subjects or having different algic syndromes. Utilizing 29 asymptomatic volunteers, the threshold of the painful perception was studied, measuring them in a direct way over the emergence of the supra-orbital, infra-orbital and mental nerves. The following algometric average were recorded: right mental nerve 46.2 Kg/cm2 and left 48.6 Kg/cm2; right supra-orbital nerve 47.7 Kg/cm2 and left 45.2 Kg/cm2; right infra-orbital nerve 53.9 Kg/cm2 and left 55.4 Kg/cm2. After reviewing the principles of the algometry utilization, we have validated this protocol, showing the average values obtained by measuring the trigeminal system, afterwards comparing them with an inervated region by cervical branches (major occipital nerve) and the temporal muscle.

Catecholamine levels in practitioners of the transcendental meditation technique

With the aim of evaluating the sympathetic-adrenal medulla system in subjects practicing transcendental meditation (TM), their plasma catecholamine levels were determined at two different times of day. The study group consisted of 19 subjects who regularly practice either TM or Sidhi-TM technique, with a control group made up of 16 healthy subjects who had not previously used any relaxation technique. Catecholamine plasma levels were determined by high performance liquid chromatography, at 0900 and 2000 h. Morning and evening norepinephrine (NE) levels and morning epinephrine (E) levels were significantly lower in the TM group than in the control subjects (morning NE levels, pg/ml, mean+/-S.E.: TM group 136.6+/-13.0, control 236.8+/-21.0, P=.0001; evening NE levels: TM group 119.7+/-10.8, control 175.6+/-17.4, P=.009; morning E levels, pg/ml: TM group 140.2+/-10.6, control 196.7+/-23.8, P=.019). No differences were recorded for evening E levels and dopamine (DA) levels. No significant differences were found for catecholamine levels measured at different times of day in the TM group, demonstrating a lack of daily hormonal rhythm. Anxiety levels were similar in both groups. Based on the results obtained, it can be considered that the regular practice of TM has a significant effect on the sympathetic-adrenal medulla system. A low hormonal response to daily stress caused by sympathetic tone regulation through regular TM could explain our results, as well as the physiological and other effects related to the field of health described in those who practice meditation.