Prognostic value of plasma circulating tumor DNA fraction across four common cancer types: a real-world outcomes study

BACKGROUND

Genomic analysis of circulating tumor DNA (ctDNA) is increasingly incorporated into the clinical management of patients with advanced cancer. Beyond tumor profiling, ctDNA analysis also can enable calculation of circulating tumor fraction (TF), which has previously been found to be prognostic. While most prognostic models in metastatic cancer are tumor type specific and require significant patient-level data, quantification of TF in ctDNA has the potential to serve as a pragmatic, tumor-agnostic prognostic tool.

PATIENTS AND METHODS

This study utilized a cohort of patients in a nationwide de-identified clinico-genomic database with metastatic castration-resistant prostate cancer (mCRPC), metastatic breast cancer (mBC), advanced non-small-cell lung cancer (aNSCLC), or metastatic colorectal cancer (mCRC) undergoing liquid biopsy testing as part of routine care. TF was calculated based on single-nucleotide polymorphism aneuploidy across the genome. Clinical, disease, laboratory, and treatment data were captured from the electronic health record. Overall survival (OS) was evaluated by TF level while controlling for relevant covariables.

RESULTS

A total of 1725 patients were included: 198 mCRPC, 402 mBC, 902 aNSCLC, and 223 mCRC. TF ≥10% was highly correlated with OS in univariable analyses for all cancer types: mCRPC [hazard ratio (HR) 3.3, 95% confidence interval (CI) 2.04-5.34, P < 0.001], mBC (HR 2.4, 95% CI 1.71-3.37, P < 0.001), aNSCLC (HR 1.68, 95% CI 1.34-2.1, P < 0.001), and mCRC (HR 2.11, 95% CI 1.39-3.2, P < 0.001). Multivariable assessments of TF had similar point estimates and CIs, suggesting a consistent and independent association with survival. Exploratory analysis showed that TF remained consistently prognostic across a wide range of cutpoints.

CONCLUSIONS

Plasma ctDNA TF is a pragmatic, independent prognostic biomarker across four advanced cancers with potential to guide clinical conversations around expected treatment outcomes. With further prospective validation, ctDNA TF could be incorporated into care paradigms to enable precision escalation and de-escalation of cancer therapy based on patient-level tumor biology.

Skin Lesions in Neurofibromatosis Type 2: Diagnostic and Prognostic Significance of Cutaneous (Plexiform) Schwannomas

Background

Neurofibromatosis type 2 (NF2) is a genetic disease characterized by the appearance of multiple tumours in the nervous system. Cutaneous lesions are common and may provide useful diagnostic and prognostic information, but they have not been widely studied.

Objectives

To characterize cutaneous lesions in a Spanish cohort of patients with NF2 and investigate associations with clinical and genetic severity.

Methods

We studied the clinical and histologic characteristics of cutaneous lesions in 49 patients with NF2 and analysed correlations with phenotype‐ and genotype‐based severity scores. We collected information on the presence/absence of cutaneous lesions, location, age at onset, type of lesion, and histologic features. We also studied level of systemic involvement and genetic mutations involved.

Results

Forty‐nine patients (31 women [63.3%] and 18 men [36.7%]) were analysed, and 33 (67.3%) had cutaneous lesions presumed to be schwannomas. According to their clinical form, they were distributed as follows: 24 patients (48%) had deep tumours, 21 (42%) had plaque‐like lesions, and 3 (6%) had superficial tumours. Histologic examination from 27 lesions analysed out 23 patients showed classic schwannoma or hybrid schwannoma‐neurofibroma features in the 8 deep tumours biopsied and plexiform schwannoma features in the 17 plaque‐like lesions and the 2 superficial tumours analysed. Early onset (first 2 decades of life) was reported by all patients with plaques and superficial tumours. In our cohort, 100% of the patients with plaque‐like lesions and superficial tumours with microscopic features of plexiform schwannoma were in the 2 groups with the most severe clinical phenotypes, and 82.6% of them were in the 3 most severe genotype‐based classes.

Conclusions and Relevance

Cutaneous lesions, specially plexiform schwannomas, are common in NF2, and they usually appear at an early age providing useful diagnostic and prognostic information. These tumours are part of the spectrum of cutaneous manifestations in this disease. Although its diagnostic and prognostic value has been pointed out, there are few studies focussed on their analysis.

Assessing inclusion of trans people in HIV national strategic plans: a review of 60 high HIV prevalence countries

INTRODUCTION

Trans people are disproportionately impacted by HIV yet have not been adequately prioritized in national HIV responses or policy documents. This review aims to understand the extent of meaningful inclusion of trans people in national strategic plans (NSPs) for HIV/AIDS as an essential step in ensuring that HIV policy aligns with epidemiologic data, and trans-specific programming is funded, implemented and sustained.

METHODS

HIV NSPs from 60 countries, across five global regions, were assessed for the level of inclusion of trans populations between January and March 2021. The most recently available NSP for each country, published after 2011, was obtained through publicly accessible online sources or through researcher networks. Data were manually extracted from NSPs using a framework of indicators focusing on trans inclusion in these five major sections of NSPs: (1) narratives; (2) epidemiological data; (3) monitoring and evaluation (M&E) indicators and targets; (4) activities; and (5) budgets.

RESULTS AND DISCUSSION

Within all reviewed NSPs, 65.0% (39/60) mentioned trans people in at least one of the five key sections but only 8.3% (5/60) included trans people in all five key sections. Trans people were more commonly mentioned in the background/narratives of NSPs (61.7%, 37/60) but less commonly included NSP activities (38.3%, 23/60), in M&E indicators and targets (23.7%, 14/60), in epidemiological data (20.0% 12/60), and in NSP budgets (13.3%, 8/60). Countries in the Asia and Pacific region most frequently included trans people in all five key sections (38%, 5/13), while no countries in Eastern and Southern Africa included trans people in all NSP sections.

CONCLUSIONS

This analysis finds substantial gaps in the inclusion of trans populations in NSPs globally. Results highlight the pressing need for states, technical partners, and international funders to engage with trans communities to improve trans-inclusion in all key sections of NSPs. Trans inclusion in NSPs is an essential step towards reaching the populations most at risk of HIV and ultimately achieving country-level epidemic control.

Correction to: Physical, Emotional, and Psychosocial Challenges Associated with Daily Dosing of HIV Medications and Their Impact on Indicators of Quality of Life: Findings from the Positive Perspectives Study

The article Physical, Emotional, and Psychosocial Challenges Associated with Daily Dosing of HIV Medications and Their Impact on Indicators of Quality of Life: Findings from the Positive Perspectives Study, written by Patricia de los Rios · Chinyere Okoli · Erika Castellanos · Brent Allan · Benjamin Young · Garry Brough · Marvelous Muchenje · Anton Eremin · Giulio Maria Corbelli · Marta McBritton · W. David Hardy· Nicolas Van de Velde was originally published electronically on the publisher’s internet portal on 17th December 2020 without open access. With the author(s)’ decision to opt for Open Choice the copyright of the article changed on 16th February 2021 to © The Author’s 2021 and the article is forthwith distributed under a Creative Commons Attribution.

Regional differences in perceived treatments needs and priorities in relation to antiretroviral therapy among people living with HIV in 25 countries

While geographic differences in HIV burden are well documented, less is known about regional differences in perceived treatment needs. To fill this gap, the 2019 Positive Perspectives study of people living with HIV (PLHIV) was conducted in 25 countries across Northern America, Latin America, the Asian region, Europe (EU/Schengen countries), Russia, Australia, and South Africa (n = 2389). Overall mean duration of HIV was 10.1 (SD = 9.6) years. The perception that HIV had a negative impact on day-to-day life was lowest among participants from South Africa (14.0%[25/179]) and highest among participants from the Asian region (55.2%[127/230]). Most of the regional gap in the perception that HIV had a negative impact on daily life was explained by regional differences in medication-related unmet needs, stigma, demographic factors, and comorbidities. The percentage who felt they understood their treatment was highest among participants from Australia (87.5%[105/120]) and lowest among those from Russia (62.0%[93/150]), the Asian region (62.2%[143/230]), and South Africa (62.6%[112/179]). Among participants from Northern America, Europe, and Latin America, the treatment goals with the largest absolute increase in perceived importance, from time of starting treatment to time of survey among those diagnosed for ≥1 year, were minimizing the long term impact of antiretroviral treatment and keeping the number of medicines in their antiretroviral regimen at a minimum. Tailored approaches to care of PLHIV are needed as different regions have different disease burden and treatment needs. Equitable approaches to HIV care are needed across and within regions to ensure that patients' unmet needs and preferences are addressed to improve their overall wellbeing and health-related quality of life.

1045. Treatment-Related Physical, Emotional, and Psychosocial Challenges and their Impact on Indicators of Quality of Life

Background

Despite effectiveness of antiretroviral therapy (ART), some people living with HIV (PLHIV) still face barriers to daily oral ART adherence, including inconvenient scheduling, food requirements, adverse effects, and privacy concerns. We characterized treatment-related physical, emotional, and psychosocial challenges among PLHIV from 25 countries.

Methods

2389 PLHIV adults on ART were surveyed in the 2019 Positive Perspectives Study, a standardized, self-reported survey of HIV patients aged 18-84 years on treatment. Data were collected on ART-related perceptions and behaviors. Descriptive and multivariable analyses were performed.

Results

Most participants were male (67.9%), aged < 50 years (70.7%), and reported viral suppression (74.1%). ART-related challenges included cueing of bad memories (58.4%), disguising HIV pills (57.9%), stress (33.3%), and difficulty swallowing pills (33.1%). Privacy and emotional challenges were generally similar between the USA and Canada (Figure 1). In the pooled sample, those who felt limited by their ART had higher odds of reporting suboptimal overall health (AOR 1.90, 95%CI:1.57-2.29), treatment dissatisfaction (AOR 2.21, 95%CI:1.82-2.69), and suboptimal adherence (AOR 1.90, 95%CI:1.57-2.29). Difficulty swallowing, any side effects, and privacy concerns were associated with increased odds of suboptimal overall health (AOR 2.10, 1.88, and 1.43, respectively) and suboptimal adherence (AOR 2.51, 1.50, and 1.87, respectively; all P< 0.05); results for other outcomes are in Figure 2. Overall, 12.6% (302/2389) had shared their HIV status solely with their primary HIV provider, whereas 6.8% (163/2389) “always” shared their HIV status. Only 52.0% were comfortable discussing ART-related privacy concerns with providers, although 29.0% overall missed ≥1 ART dose in the past month from privacy concerns. Overall, 54.7% preferred a nondaily regimen if their HIV stays suppressed, while 72.3% were open to ART with fewer therapies.

Figure 1

Figure 2

Conclusion

This study identified several challenges with ART among PLHIV, underscoring the need for increased flexibility of ART delivery to meet diverse patient needs. Addressing these needs may improve overall health outcomes for more PLHIV on therapy.

Disclosures

Patricia De Los Rios, MSc, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Chinyere Okoli, PharmD, MSc, DIP, ViiV Healthcare (Employee) Benjamin Young, MD, PhD, ViiV Healthcare (Employee) Garry Brough, BA Joint Hons in French/Italian, ViiV Healthcare (Employee, Independent Contractor, Other Financial or Material Support, Speakers Fees and Honoraria) Anton Eremin, MD, ViiV Healthcare (Advisor or Review Panel member) Marvelous Muchenje, BSW, MSc. in Global Health, ViiV Healthcare Canada (Employee) Nicolas Van de Velde, PhD, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee)

Prevalence, determinants, and impact of suboptimal adherence to HIV medication in 25 countries

Modern antiretroviral therapy (ART) has improved the lives of people living with HIV (PLHIV) but currently requires daily adherence. We assessed prevalence and correlates of suboptimal adherence, and measured associations with self-reported health outcomes. Data were from web-based surveys of confirmed HIV+ adults on antiretroviral treatment within 25 countries during 2019 (n = 2389). Suboptimal adherence was a report of ≥1 reason for missing ART ≥5 times within the past month. Multivariable logistic regression examined associations between suboptimal adherence and self-reported overall health and virologic suppression. Overall, 24.1% (575/2389) reported suboptimal adherence, from 10.0% (5/50) in Austria, to 62.0% (31/50) in China. The most common reasons for missing ART ≥5 times in the overall population were feeling depressed/overwhelmed (7.4%, 176/2389), trying to forget about HIV (7.0%, 168/2389), and work (6.1%, 145/2389). Correlates of suboptimal adherence included being heterosexual, <50 years old, ≤high school, having gastrointestinal treatment side effects, and privacy concerns. Odds of suboptimal overall health were 1.41 (95%CI, 1.11-1.80), 2.10 (95%CI, 1.65-2.68), and 2.55 (95%CI, 2.00-3.25) among those who reported the maximum number of times missed ART for any reason within the past month as 1, 2-4, or ≥5 times respectively, vs not missing at all. Odds of virologic nonsuppression were 1.80 (95%CI, 1.33-2.45), and 2.24 (95%CI, 1.66-3.02) for 2-4, or ≥5 times of missed ART respectively, vs not missing at all; missing for only 1 time was not significantly associated with virologic nonsuppression. Novel ART strategies designed to improve adherence along with interventions to empower PLHIV and support self-medication may improve health outcomes and quality of life.

Barriers and facilitators to past six-month HIV testing among men who have sex with men in Belize

Prevalence of HIV in Belize is high, and men who have sex with men (MSM) are disproportionately impacted by HIV. HIV testing is critical in curbing the epidemic; however, little is known about factors associated with testing among MSM in Belize. Working with a non-governmental organization in a large, urban city within Belize, snowball sampling was applied to recruit Belizean MSM to complete a self-administered survey. Multivariable logistic regression analysis was employed to understand associations with HIV screening behavior. Access to healthcare, HIV knowledge, and reporting having heard of Section 53 of the Criminal Code of Belize (once outlawing same-sex sexual behavior), but not experiencing any negative impact from Section 53 were significantly positively associated with having received an HIV test in the past six months. Healthcare maltreatment (lifetime), depression symptomology, and shame were significantly negatively associated with having received a HIV test in the past six months. Findings suggest that multiple factors associated with stigma and discrimination negatively affect testing strategies among MSM in Belize.

Undetectable equals untransmittable (U = U): awareness and associations with health outcomes among people living with HIV in 25 countries

Objectives

‘Undetectable equals Untransmittable’ (U=U) is an empowering message that may enable people living with HIV (PLHIV) to reach and maintain undetectability. We estimated the percentage of PLHIV who ever discussed U=U with their main HIV care provider, and measured associations with health-related outcomes. Secondarily, we evaluated whether the impact of the U=U message varied between those who heard it from their healthcare provider (HCP) vs from elsewhere.

Methods

Data were from the 25-country 2019 Positive Perspectives Survey of PLHIV on treatment (n=2389). PLHIV were classified as having discussed U=U with their HCP if they indicated that their HCP had ever told them about U=U. Those who had not discussed U=U with their HCP but were nonetheless aware that ‘My HIV medication prevents me from passing on HIV to others’ were classified as being made aware of U=U from non-HCP sources. Multivariable logistic regression was used to measure associations between exposure to U=U messages and health outcomes.

Results

Overall, 66.5% reported ever discussing U=U with their HCP, from 38.0% (South Korea) to 87.3% (Switzerland). Prevalence was lowest among heterosexual men (57.6%) and PLHIV in Asia (51.3%). Compared with those unaware of U=U, those reporting U=U discussions with their HCP had lower odds of suboptimal adherence (AOR=0.59, 95% CI 0.44 to 0.78) and higher odds of self-reported viral suppression (AOR=2.34, 95% CI 1.72 to 3.20), optimal sexual health (AOR=1.48, 95% CI 1.14 to 1.92) and reporting they ‘always shared’ their HIV status (AOR=2.99, 95% CI 1.42 to 6.28). While exposure to U=U information from non-HCP sources was beneficial too, the observed associations were attenuated relative to those seen with reported discussions with HCPs.

Conclusion

HCP discussion of U=U with PLHIV was associated with favourable health outcomes. However, missed opportunities exist since a third of PLHIV reported not having any U=U discussion with their HCP. U=U discussions with PLHIV should be considered as a standard of care in clinical guidelines.

Polymorphisms in gyrA and gyrB genes among Mycobacterium avium subsp. paratuberculosis type I, II, and III isolates

The analysis of the gyrA and gyrB genes of a panel of Mycobacterium avium subsp. paratuberculosis isolates from types I, II, and III detected type-specific single nucleotide polymorphisms. Based on these results, we developed a PCR and restriction enzyme analysis to discriminate type I and III isolates. The application of this technique would be the unique strategy to characterize these strains when there is not enough bacterial growth to perform pulsed-field gel electrophoresis and IS900 restriction fragment length polymorphism.

Mediastinal paraganglioma irrigated by coronary vessels in a patient with an atypical chest pain

We present a case of non-functioning anterior mediastinal paraganglioma in a 61-year-old woman. The tumour was accidentally discovered on a coronary angiography performed in an atypical precordial pain and dyspnea. The coronary angiography showed a vascular tumour in the paraaortic localization irrigated from two branches of coronary arteries. Diagnosis was confirmed by a thoracic tomographic scan which revealed an anterior mediastinal tumour. Complete tumour resection was done through a sternotomy with extracorporeal circulation without cardiac arrest. The histological examination of the operative specimen was characteristic of paraganglioma.

The role of mast cell tryptase in neoangiogenesis of premalignant and malignant lesions of the uterine cervix

Recently, mast cell tryptase has been identified as another potent proangiogenic factor in tumors, along with fibroblast and vascular endothelial growth factors. Its role has been studied in a number of cancers, including carcinoma of the uterine cervix, with discordant results. Our aim was to study the expression of tryptase and bFGF in mast cells (MCs) during development of neoangiogenesis in premalignant and malignant lesions of the cervix. Biopsy specimens from 21 patients without cancer and from 63 patients with dysplasias and squamous cell carcinomas were used. They were stained with Alcian blue-safranin O (ABSO) and immunostained with specific antibodies against factor VIII, CD105, tryptase, and bFGF. Tryptase-positive mast cells increased with tumor progression and were close to newly formed blood vessels. Vascularization showed a linear increase from dysplasia to invasive cancer. We suggest that MC tryptase may upregulate neoangiogenesis in carcinogenesis of the uterine cervix.

[Ventricular arrhythmias induced by appropriate antibradycardia pacing in patients with implantable defibrillators]

INTRODUCTION AND OBJECTIVES

The induction of ventricular arrhythmias by appropriate antibradycardia ventricular pacing in patients with implantable cardioverter defibrillators has been reported in only a few cases. The aim of this study was to assess the incidence, characteristics and management of these episodes.

METHODS

The follow-up records of 180 patients with implantable cardioverter defibrillators with intracardiac electrogram storage were reviewed. Pacing induced episodes were defined as those occurring immediately after an appropriate paced stimulus in a patient with sporadic paced beats. We assessed the number and type of episodes, mode of onset, therapy administered and the efficacy of different prevention measures.

RESULTS

Pacing induced episodes were found in 9 patients (5%). Seven received device administered therapy which was effective in all cases. One to 95 episodes were observed per patient, of which 138 were monomorphic ventricular tachycardias and 20 polymorphic ventricular tachycardia/ventricular fibrillation episodes. All were induced by a paced ventricular beat after a post-extrasystolic pause or after long RR intervals during atrial fibrillation. Pacing induced arrhythmias were prevented by changing the pacing rate or hysteresis in 3 out of 6 patients and by decreasing the stimulus energy in 3 out of 3. Antibradycardia pacing function was disabled in 4 patients.

CONCLUSIONS

Ventricular arrhythmias induced by appropriate antibradycardia ventricular pacing are relatively common in patients with implantable cardioverter defibrillators. Effective prevention can be achieved in most cases by changing the pacing rate or the pacing stimulus energy, however in selected cases the antibradycardia function may be disabled.

Human immunodeficiency virus infection in pregnant women, transmission and zidovudine therapy

OBJECTIVE

To determine the rate of mother to child transmission of HIV infection in women treated with zidovudine (ZDV).

PATIENTS AND METHODS

A consecutive series of 52 HIV-positive pregnant women who either received antenatal care or delivered at our institution. Forty-three women were known to be HIV positive before delivery. Forty were treated with ZDV, 36 intravenously. Twelve had no antenatal care and one refused antenatal treatment. All neonates were treated with ZDV.

RESULTS

The HIV transmission rate in children born to mothers treated with ZDV was 6.6%. This compares with a transmission rate of 14% before we used ZDV. All three mothers who transmitted infection had low compliance, initiated therapy late in pregnancy or had advanced disease.

CONCLUSION

Our experience supports the idea that ZDV treatment has reduced HIV transmission rate.

Neuronal differentiation of chromaffin cells in vitro, induced by extremely low frequency magnetic fields or nerve growth factor: a histological and ultrastructural comparative study

The application of nerve growth factor (NGF) to primary adrenal medulla chromaffin cell cultures induces phenotypic changes characterized mainly by the presence of neurites. A similar effect has been seen when these cells are stimulated by extremely low frequency magnetic fields (ELFMF). In this study, newborn rat chromaffin cells were cultured and subjected to NGF or ELFMF in order to compare their histological and ultrastructural characteristics. Cells cultured in the presence of NGF developed cytoplasmic projections and their distal ends showed growth cones as well as filopodia. With scanning and transmission electron microscopy, an increased submembranous electron density was observed in the nuclei of cells as well as irregular, wavy neuritic projections with a moderate number of varicosities, as well as the prevalence of intermediate filaments among the cytoskeleton components. Cells stimulated with ELFMF presented straighter neuritic extensions with a greater number of varicosities. With the transmission electron microscope, numerous neurotubules were observed, both in the cell soma and in their neuritic extensions. In both groups, growth cones were clearly identified by their ultrastructural characteristics. The differences seen in the cytoskeleton of cells stimulated with NGF or ELFMF suggest differential stimulation mechanisms possibly determining the biochemical, electrophysiological, and morphological characteristics in both types of cell cultures.

First postpacing interval variability during right ventricular stimulation: a single algorithm for the differential diagnosis of regular tachycardias

BACKGROUND

Failure to differentiate supraventricular from ventricular arrhythmias is the most frequent cause of inappropriate implantable cardioverter-defibrillator therapies. Although a sudden-onset criterion is available to differentiate sustained monomorphic ventricular tachycardias (SMVTs) and sinus tachycardias (STs), SMVTs arising during ST and SMVTs gradually accelerating above the cutoff rate can remain undetected. Regular paroxysmal atrial tachycardias (ATs) also can be undetected by onset and stability algorithms. We hypothesized that the first postpacing interval (FPPI) variability after overdrive right ventricular pacing may differentiate SMVTs from STs and ATs.

METHODS AND RESULTS

FPPI variability was measured in 23 SMVTs (cycle length [CL] 366+/-50 ms [VT group]), 27 supraventricular tachycardias, 15 episodes of induced or simulated ATs (CL 376+/-29 ms [AT group]), and 12 exercise-related STs (CL 381+/-24 [ST group]). Sequences of trains of 5, 10, and 15 beats were delivered with a CL 40 ms shorter than the tachycardia CL. An FPPI absolute mean difference between consecutive trains of 5 and 10 beats (deltaFPPI) < or =25 ms identified all VTs (mean difference 5+/-7 ms). In the AT group, the deltaFPPI was >25 ms in all sequences (mean difference 129+/-60 ms, P<0.01). In the ST group, the deltaFPPI was >50 ms in all STs (mean difference 118+/-47 ms, P<0.01).

CONCLUSIONS

FPPI variability may differentiate SMVT from AT and ST. This criterion is potentially useful in implantable devices that use a single ventricular lead.

Cytologic atypia. Clinical significance and follow-up recommendations

OBJECTIVE

To assess the evolution of cytologic atypia on cervical cytologic smears as an attempt to better understand the natural history of these lesions and to establish a follow-up protocol.

STUDY DESIGN

The study group consisted of 76 patients with a diagnosis of cytologic atypia on cervical cytologic smears performed at the gynecology Outpatient Clinic, Hospital del Mar, between December 1989 and June 1993. Patients with inflammatory atypia, a reparative process or findings consistent with human papillomavirus infection had been excluded. Follow-up smears were reviewed. Compliance with follow-up recommendations was also evaluated.

RESULTS

Thirty-nine patients returned to the clinic for follow-up after a diagnosis of atypia (51.3%). Progression from atypia to dysplasia was found in 38.5% of patients with at least a follow-up smear. Changes consistent with intraepithelial neoplasia were found in 17 patients: low grade dysplasia was found in 10 patients (mild dysplasia in 8 and atypia in 2) and high grade dysplasia in 7 (moderate in 4 and severe in 3). This progression was most commonly found at the first follow-up visit and within the first year.

CONCLUSION

Patients with cytologic atypia were at higher risk of developing dysplasia than those with reparative atypia. Our results support the theory of progression from atypia to dysplasia in a considerable percentage of patients. Follow-up compliance in our patient population was low. One should emphasize the importance of this diagnosis and encourage close cytologic follow-up, especially within the first year after the diagnosis of atypia.

Intermittent aortic regurgitation following aortic valve replacement

Intermittent aortic regurgitation is an unusual complication following a mechanical prosthesis replacement in the early postoperative period. Arterial pressure recording and echocardiographic assessment were enough to diagnose the prosthetic dysfunction. Reexploration of the valve confirmed the dysfunction, which was caused by a pannus of previous aortic valve replacement with the pulmonary valve. The pannus impeded normal closure of the leaflet in an intermittent way during diastole. Reorientation of the valve corrected the aortic insufficiency. Doppler ultrasound was a very useful noninvasive technique in order to evaluate the suspected prosthetic valve dysfunction in the immediate postoperative period.

Hyperammonaemic encephalopathy as the presenting feature of IgD multiple myeloma

We observed a case of hyperammonaemic encephalopathy in a patient without liver dysfunction which revealed meningeal involvement of IgD multiple myeloma. We have reviewed briefly the hyperammonaemic syndrome and we believe that this diagnosis has to be considered in differential diagnosis of encephalopathies in patients with multiple myeloma.

A comparative study of the St. Jude Medical and Björk-Shiley convexo-concave prostheses in isolated valve replacement

This is a study of 199 consecutive patients who survived isolated mitral or aortic valve replacement with a Björk-Shiley (B-S) or St. Jude Medical (SJM) prostheses. Mean follow-up was 36 months. Preoperative status was similar for both groups (B-S or SMJ). Five year survival rates for mitral valve replacement (MVR) were 91% for B-S and SJM, and for aortic valve replacement (AVR) 96% vs 91% for SJM (p less than 0.06). Linearized incidence of thromboembolism in MVR was 5.62% patient year for BS and 5.23% patient year for SJM (p = NS). Classical risk factors for thromboembolism were evaluated on a univariate analysis: no single risk factor was identified. Only the association of two or more was possibly significant. The presence of inadequate anticoagulation (prothrombin index greater than 50%) was the main risk factor for thromboembolism, as the incidence rate was 19% per patient year when poorly anticoagulated versus 4.6% per patient year incidence in the whole series (p less than 0.01).

[The 2-dimensional and Doppler color echocardiographic study of a congenital aneurysm of the sinus of Valsalva with a fistula of the right atrium in an adult]

This report describe a 69-year old woman with a congenital aneurysm of the non-coronary sinus of Valsalva ruptured in the right atrium, causing severe hemodynamic derangement of the right ventricle. The site of the communication between the aneurysm and the receiving chamber was accurately diagnosed by two-dimensional color flow Doppler imaging which provided more valuable preoperative information than conventional aortography.

Ultrastructural studies of rat arteriosclerosis induced by stimulation of the immune system with ovalbumin

Intimal thickening in the aorta and carotid artery of rats was induced by repeated intraperitoneal injections of ovalbumin, 2.5 mg/kg BW, given weekly 5 times after initial subcutaneous sensitization, and/or feeding with a cholesterol-rich diet. The intimal thickening was apparent in immune-challenged rats fed with either a cholesterol-rich or a basal diet (p less than 0.01), whereas it was mild in non-immunized rats fed a cholesterol-rich diet. The ultrastructural changes in the thickened intima were characterized by leukocytic (mainly monocytic) adhesion and migration, and minor endothelial cell damage. Morphometric evaluation of leukocyte adhesion to the intima of the thoracic aorta revealed that the immunized rats fed either a cholesterol-rich or a basal diet showed greater leukocytic adhesion (p less than 0.01 and p less than 0.001, respectively) than that in non-immunized rats fed a cholesterol-rich diet, which in turn also showed an increased degree of leukocyte adhesion (p less than 0.05) than control rats. This immunological approach to the arteriosclerotic process could explain the earlier and more severe arteriosclerosis found in patients with immunological disorders, and the development of arteriosclerosis in the absence of hypercholesterolemia, hypertension and other risk factors.

Chronic dissection of the anterior tibial artery leading to acute aneurysmal dilatation

We present a clinical case of chronic dissection of the anterior tibial artery leading to acute aneurysmal dilatation. Our patient, a 22-year-old man, had a history of trauma at the middle third of his left leg. Because of impending ischemia, he was diagnosed by emergency arteriography. We ligated the proximal and distal ends of the dissection and used a reversed saphenous vein for a short end-to-end bypass. Although the evolution of this dilatation had been silent, its clinical presentation was spectacular. The case is worthy of attention because of its extreme rarity, both as a dissection of a peripheral artery caused by trauma and as an aneurysmal dilatation at tibial level.

Dietary factors and prostatic cancer

In order to learn about the influence of dietary factors and obesity on prostatic cancer in our environment, a case-control study was performed. The group of cases consisted of 90 men histologically diagnosed with prostatic cancer in the 'La Paz' hospital (Madrid) during the 4-year period of 1983-1987. The controls were 180 men selected to obtain a random sample of males from the same hospital, stratified according to age and date of admission as compared with the prostatic cancer patients. The results of the study revealed that a diet rich in animal fats as well as high in meat consumption increased the risk of prostatic cancer. Low ingestion of vitamin A or vitamin C and obesity were unassociated to the disease.

Anomalous origin of the left coronary artery from the pulmonary artery. Surgical alternatives depending of the age of the patient

Four cases of anomalous origin of the left coronary artery from the pulmonary artery, three of which were operated upon in our Centre, are presented. An aortocoronary bypass with reversed autologous saphenous vein was carried out in both of the children; and in the adult, the anomalous ostium was closed from the interior of the pulmonary artery. After 84, 72, and 4 months of evolution, respectively, they were found to be asymptomatic, the mitral insufficiency had disappeared and the venous graft remained patent. In this paper, the clinical form of presentation, diagnostic possibilities and surgical treatment are analysed.

Sustained arterial injury and progression of atherosclerosis

In this paper the following findings were described: 1) Murine arteriosclerosis induced by immune challenge was ultrastructurally characterized by intimal monocyte-macrophage recruitment and minor endothelial alterations; 2) Atherosclerotic lesions of human coronary arteries exhibited frequently segmental or patchy neovascularization, probably representing a response to intimal injury as an example of repair process. Newly formed blood vessels in the intima were derived from both adventitial and luminal endothelial growth; 3) Angiogenesis in vitro was related to the activation of fibrinolytic system especially via the autocrine production of u-PA from endothelial cells, and this process was modulated by cytokines and TGF beta. These findings add more evidence for the hypothesis that the chronic inflammation-repair process plays an essential role in the initiation and progression of atherosclerosis.

[Factors associated with cancer of the prostate]

An epidemiological case-control study was performed to know the factors involved in the development of prostatic cancer. Ninety patients diagnosed of prostatic cancer in La Paz Hospital (Madrid) from January, 1981 to December, 1987, comprised the study group. The controls were 180 male patients from the same hospital and with no personal or familial antecedents of urologic disease or malignant tumours. The cases and controls were matched by age, and year of admission to the hospital. The results of the study revealed that the disease is strongly associated to familial antecedents of prostatic cancer. The risk for the patients with these antecedents is 3.14. The disease was statistically associated to a fatherhood of more than 5 children. No association between the disease and antecedents of tonsillectomy, rheumatic fever, educational level, place of residence, or marital status was found.