Efficacy and safety of dolutegravir/rilpivirine in real-world clinical practice. GeSIDA study 1119

INTRODUCTION

Dolutegravir/rilpivirine (DTG/RPV) is an effective antiretroviral (ART) regimen endorsed by clinical trials as a switch therapy. The aim of our study was to analyse the efficacy and safety of DTG/RPV in real-world clinical practice.

METHODS

Observational, multicentre study of patients who started DTG/RPV. Efficacy, adverse events and metabolic changes at 48 weeks were analysed.

RESULTS

A total of 348 patients were included; median time of HIV infection was 21.1 years, 33.7% were AIDS cases; median nadir CD4 was 160 cells/μL; 90.5% had received ≥3 lines of ART and 179 (53.8%) had prior virological failure. Convenience (43.5%), toxicity/intolerance (28.4%) and interactions (17.0%) were the main reasons for starting DTG/RPV. Previous regimens were protease inhibitors (PI) (31.6%), non-nucleoside reverse transcriptase inhibitors (NNRTI) (20.4%) and integrase strand transfer inhibitors (INSTI) (14.9%). Efficacy (HIV-RNA <50 copies/mL) at 48 weeks was 89.7% (95% CI 86.1-92.6) by intention-to-treat (ITT) and 94.2% (95% CI 91.3-96.4) by on treatment (OT); 10 patients (3.1%) were not suppressed (3 had abandoned ART). There was a mean decrease in triglycerides, total cholesterol, low-density lipoprotein-cholesterol, glutamic-pyruvic transaminase (GPT), gamma-glutamyl transferase (GGT) and alkaline phosphatase; creatinine increased with a decrease in glomerular filtration rate.

CONCLUSIONS

This study confirms the effectiveness, tolerability and safety of DTG/RPV in real-world clinical practice in a different population from clinical trials, with many years of infection, low CD4 nadir, several previous treatment lines, more than half with virological failures, and one-third diagnosed with AIDS. The switch to DTG/RPV was safe with few discontinuations due to adverse effects. Modifications of the lipid and liver profiles were favourable. There were no relevant changes in kidney function.

Safety and Efficacy of Dolutegravir Plus Rilpivirine in Treatment-Experienced HIV-Infected Patients: The DORIVIR Study

Objectives:

To analyze the efficacy and safety of dolutegravir/rilpivirine (DTG/RPV) in HIV-infected patients who switched from any other antiretroviral therapy (ART).

Methods:

Open-label, multicenter study including patients who switched to DTG/RPV between February 2015 and February 2016. Efficacy (HIV RNA <50 copies/mL), adverse events, and metabolic changes at 24 weeks were analyzed.

Results:

A total of 104 participants were included, who switched for the following reasons: toxicity/intolerance (42.3%), convenience (27.8%), and drug interactions (17.3%). Prior regimens are protease inhibitor (56.7%), integrase strand transfer inhibitor (26.9%), and non-nucleoside reverse transcriptase inhibitor (16.3%). Efficacy at 24 weeks was 88.4% (intention to treat) and 96.8% (per protocol). Triglyceride levels were reduced, on average, by 12.7% and a mean decrease of 9.0% in the glomerular filtration rate was observed as well (P values of .003 and .002, respectively), whereas total cholesterol, HDL cholesterol, LDL cholesterol, creatinine, and glutamic-pyruvic transaminase remained unchanged. No patient discontinued due to adverse events.

Conclusions:

Dolutegravir/RPV is effective and safe in long-term HIV-infected patients under any prior ART. Toxicity, convenience, and interactions were the main reasons for changing. At 24 weeks, the lipid profile improved with a decrease in triglycerides.

Effect of sperm dosage transportation in stallions: Effect on sperm DNA fragmentation

Artificial insemination programs for horses usually involve ex vivo handling and transporting of sperm. The present experiment was designed to: (i) assess the effect of transportation on sperm DNA integrity at different time post semen collection, and (ii) evaluate if sperm DNA quality deteriorates rapidly beyond 24 h of cooled storage. After collection, the ejaculates were extended using INRA 96 and semen was prepared for prompt analysis (A0) or 24 h/48 h cooled-shipping (B24 and C48 respectively). Each sample was assessed for sperm DNA fragmentation index (SDFI) at time 0 and after incubation for 2, 6 and 24 h at 37 °C. There was very little difference in SDFI between freshly extended (A0) and 24 h/48 h cooled-transported semen samples (B24/C48) at time 0. After 2 h of incubation at 37 °C, there was an increase in SDFI ranging from 2.7% to 7.5% per hour in freshly extended semen samples (A0: 5.1 ± 1.5), while cooled-transported semen samples had a much greater increase in SDFI, ranging from 5.0% to 20.5% (B24: 14.7 ± 5.6) and from 8.2% to 26.8% (C48: 18.3 ± 7.2) respectively. There were not marked differences in the sperm DNA integrity between 24 and 48 h for transported samples, thus there is the possibility of desirable fertility with use of stallion sperm after 48 h of cooled storage.

Results of an early intervention programme for patients with bacteraemia: analysis of prognostic factors and mortality

Background

Bacteraemia is a common cause of morbidity and mortality in patients admitted to hospital. The aim of this study is to analyse the results of a two-year programme for the early optimisation of antibiotic treatment in patients admitted to the Costa del Sol Hospital (Marbella. Spain).

Methods

A prospective two-year cohort study was conducted, evaluating all episodes of bacteraemia at the Costa del Sol Hospital. Epidemiological and microbiological characteristics, any modification of the initial antibiotic treatment, prognostic risk stratification, early mortality related to the episode of bacteraemia, and mortality after the seventh day, were included in the analysis.

Results

Seven hundred seventy-three episodes of bacteraemia were treated, 61.6% males and 38.4% females. The mean age was 65.2 years. The condition was most commonly acquired in the community (41.4%). The bacteraemia was most frequently urological in nature (30.5%), and E coli was the microorganism most frequently isolated (31.6%). In 51.1% of the episodes, a modification was made to optimise the treatment. In the first week, 8.2% died from bacteraemia, and 4.5% had died when they were located. The highest rates of death were associated with older patients, nosocomial acquisition, no source, McCabe score rapidly fatal, Charlson index ≥3, Pitt index ≥3 and treatment remained unmodified.

Conclusion

The existence of bacteraemia control programmes and teams composed of clinicians who are experienced in the treatment of infectious diseases, can improve the disease outcome by enabling more severe episodes of bacteraemia to be recognised and their empirical treatment optimised.

Equivalent seminal characteristics in human and stallion at first and second ejaculated fractions

Sperm quality was assessed in normozoospermic human (n = 10) and Spanish breed stallion (n = 10) after sperm fractionation during ejaculation. The first ejaculated fraction was separated from the second. A third sample was reconstituted using equivalent proportion of both fractions (RAW). Fraction 1, Fraction 2 and RAW semen were incubated for 30 min at 37°C to homogenise the impact of iatrogenic damage between both species. Sperm concentration, motility and sperm DNA damage were assessed in each fraction and RAW semen. The results showed two important facts: (i) spermatozoa confined at Fraction 1 exhibit superior parameters than those included at Fraction 2 in both species, and (ii) there is a certain level of concordance between species in the proportion of benefit observed when Fraction 1 is compared to RAW semen. Altogether, these results call into question whether the standard practice of whole ejaculate collection can be considered the best strategy when using male gametes for artificial insemination. In fact, the reconstituted RAW semen exhibits poorer semen characteristics than those found in Fraction 1.

Transmission of HIV Drug Resistance and the Predicted Effect on Current First-line Regimens in Europe

Transmitted human immunodeficiency virus drug resistance in Europe is stable at around 8%. The impact of baseline mutation patterns on susceptibility to antiretroviral drugs should be addressed using clinical guidelines. The impact on baseline susceptibility is largest for nonnucleoside reverse transcriptase inhibitors.

Background. Numerous studies have shown that baseline drug resistance patterns may influence the outcome of antiretroviral therapy. Therefore, guidelines recommend drug resistance testing to guide the choice of initial regimen. In addition to optimizing individual patient management, these baseline resistance data enable transmitted drug resistance (TDR) to be surveyed for public health purposes. The SPREAD program systematically collects data to gain insight into TDR occurring in Europe since 2001.

Methods. Demographic, clinical, and virological data from 4140 antiretroviral-naive human immunodeficiency virus (HIV)–infected individuals from 26 countries who were newly diagnosed between 2008 and 2010 were analyzed. Evidence of TDR was defined using the WHO list for surveillance of drug resistance mutations. Prevalence of TDR was assessed over time by comparing the results to SPREAD data from 2002 to 2007. Baseline susceptibility to antiretroviral drugs was predicted using the Stanford HIVdb program version 7.0.

Results. The overall prevalence of TDR did not change significantly over time and was 8.3% (95% confidence interval, 7.2%–9.5%) in 2008–2010. The most frequent indicators of TDR were nucleoside reverse transcriptase inhibitor (NRTI) mutations (4.5%), followed by nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations (2.9%) and protease inhibitor mutations (2.0%). Baseline mutations were most predictive of reduced susceptibility to initial NNRTI-based regimens: 4.5% and 6.5% of patient isolates were predicted to have resistance to regimens containing efavirenz or rilpivirine, respectively, independent of current NRTI backbones.

Conclusions. Although TDR was highest for NRTIs, the impact of baseline drug resistance patterns on susceptibility was largest for NNRTIs. The prevalence of TDR assessed by epidemiological surveys does not clearly indicate to what degree susceptibility to different drug classes is affected.

Simplicity and Efficacy of a Once-Daily Antiretroviral Regimen with Didanosine, Lamivudine, and Efavirenz in Naïve Patients: The VESD Study

PURPOSE

Our aim was to analyze the efficacy and safety of didanosine-lamivudine-efavirenz in a cohort of HIV patients starting antiretroviral therapy between January and September 2003.

METHOD

We undertook a prospective, open-label, observational, multicenter study.

RESULTS

163 patients were enrolled. Over a 48-week period, plasma HIV RNA levels declined sharply, with a median decrease at the end of the observation time of >4.62 log copies/mL. The proportion of patients achieving a plasma HIV RNA level below 50 copies/mL was 62.9% (intention-to-treat analysis) at the end of the study period. The mean CD4 cell count increased steadily over time by 199 cells/microL. Antiviral efficacy was similar in patients with a baseline HIV RNA level above or below 100,000 copies/mL. Overall, 57 (34.1%) patients interrupted therapy; 9 due to lack of treatment response, 18 due to adverse side-effects, and 30 patients lost to follow-up or who withdrew their consent. Adherence was very high (90%-95%) and quality of life was good or very good in 69%.

CONCLUSION

The once-daily combination of didanosine-lamivudine-efavirenz resulted in sustained viral suppression and was well-accepted by patients under real-life conditions, even immunosuppressed patients and those with a high viral load. Associated adverse events and virological failures were few.

Wolbachia effects in natural populations of Chorthippus parallelus from the Pyrenean hybrid zone

We evaluate for the first time the effect of Wolbachia infection, involving two different supergroups, on the structure and dynamics of the hybrid zone between two subspecies of Chorthippus parallelus (Orthoptera) in the Pyrenees. Wolbachia infection showed no effects on female fecundity or a slight increment in females infected by F supergroup, although in the last case it has to be well established. Cytoplasmic incompatibility (CI) is confirmed in crosses carried out in the field between individuals from a natural hybrid population. This CI, registered as the relative reduction in embryo production (sh ), was of sh = 0.355 and sh = 0.286 in unidirectional crosses involving B and F supergroups, respectively. CI also occurred in bidirectional crosses (sh = 0.147) but with a weaker intensity. The transmission rates of the two Wolbachia strains (B and F) were estimated by the optimization of a theoretical model to reach the infection frequencies observed in certain population. To fit this scenario, both supergroups should present transmission rates close to 1. Further, we have simulated the infection dynamics, and hence, the capacity of Wolbachia to structure the population of the host insects and to affect to reproduction and genetic introgression in the hybrid zone. This represents a first example of the influence of Wolbachia in an insect natural hybrid zone.

Liver involvement in HIV-infected patients with early syphilis

The aim of the paper is to analyse the prevalence of liver involvement and related factors in HIV-infected patients with early syphilis (<2 years). Liver involvement was defined as an elevation above normal ranges of alanine transaminase, aspartate aminotransferase, gamma-glutamyltransferase and/or alkaline phosphatase during early syphilis, or doubling of previous levels in patients with liver enzyme elevation before syphilis. We undertook a multicentre study and of the 147 cases, 86.4% were men who had sex with men, and the diagnoses of syphilis and HIV infection were coincident in 48 (32.7%). Liver involvement was detected in 45 (30.6%) and the only related factor was a rapid plasma reagin (RPR) titre ≥1/64 (odds ratio 3.76; 95% confidence interval 1.3-10.5; P = 0.012). In conclusion, liver involvement occurs in around one-third of HIV-infected patients with early syphilis and is associated with high RPR levels. Syphilis should be included in the differential diagnosis of liver enzyme elevation in HIV-infected patients.

Left ventricular mass in HIV-infected patients

BACKGROUND

The HIV infection has been associated with an increased incidence of vascular events. Left ventricular mass (LVM) is independently associated with greater overall mortality. Various studies have shown that patients with HIV infection have higher LVM than the uninfected population. We aim to describe the distribution of LVM in an extensive series of patients with HIV infection, and the factors associated with its increase.

PATIENTS AND METHODS

A cross-sectional study was performed in HIV-infected patients followed in our center from 1 December 2009 to 28 February 2011. A transthoracic echocardiography (TTE) was performed in all patients who gave their consent. Demographic variables, viroimmunological status, cardiovascular risk factors, vascular risk at 10 years (VR10) and history of exposure to antiretroviral drugs were collected. LVM was considered to be the quantitative dependent variable. A univariate analysis was performed, including in the multivariate analysis those variables with P<,05.

RESULTS

A TTE was performed in 400 patients, and the LVM was calculated in 388. Mean age was 45 years, 75.5 males. Mean LVM was 39.54g/m(2.7)(95% CI: 38.35-40.73). Age, height, body mass index, VR10, hypertension, dyslipidemia, different medications within the cardiovascular area and having taken nevirapine have been used in the history of the patient were associated to greater LVM. In the multivariate analysis, use of nevirapine in the history of the patient and VR10 remained in the model.

CONCLUSIONS

VR10 may be associated with greater LVM. The relationship with nevirapine may respond to an indication bias.

Glutathione S-transferase P1 c.313A > G polymorphism could be useful in the prediction of doxorubicin response in breast cancer patients

BACKGROUND

Identification of predicting factors for anthracyclines-based chemotherapy remains a clinical challenge. Glutathione S-transferase (GSTs) enzymes detoxify chemotherapy drugs and their metabolites. Several polymorphisms in GST genes result in reduced or no activity of the enzymes. Specifically, GSTM1 and GSTT1 genes are polymorphically deleted, the polymorphism GSTP1 c.313A>G (rs1695) determines the amino acid substitution Ile105Val, where the Val-containing enzyme has reduced activity. Also, GSTA1*B allele has reduced levels of GSTA1 enzyme. Several polymorphisms in GSTs have been associated with differences in survival for cancer patients treated with chemotherapy.

PATIENTS AND METHODS

We genotyped a total of five polymorphisms in GSTM1, GSTT1, GSTP1 and GSTA1 genes in 159 patients with locally advanced breast cancer, treated with single-agent doxorubicin or docetaxel (Taxotere). Gene expression microarrays were performed in 67 breast tumor samples. We correlate this data with treatment outcome.

RESULTS

In multivariate analysis, patients homozygous GG for GSTP1 c.313A>G SNP had a lower risk of chemoresistance when treated with doxorubicin (odds ratio 0.106; confidence interval 0.012-0.898; P=0.040). No association was found in the docetaxel arm. Also, we found that GSTP1 expression varied significantly among breast cancer molecular subtypes.

CONCLUSIONS

GSTP1 may constitute another tool contributing to individualized anthracycline-based therapy.

Genomic predictors of response to doxorubicin versus docetaxel in primary breast cancer

Taxanes and anthracyclines improve the outcome of early breast cancer, although the benefit is limited to a small proportion of patients and are toxic. We prospectively looked for predictors of response to these drugs.

EXPERIMENTAL DESIGN

Four cycles of doxorubicin (75 mg/m²) or docetaxel (100 mg/m²) were compared as presurgical chemotherapy for breast cancer. Biomarkers were determined by immunohistochemistry and fluorescent in situ hybridization using prechemotherapy core biopsies. Tumors were also classified into one of the molecular intrinsic subtypes using an immunohistochemical panel of five biomarkers and genomic profiles. Single genes and intrinsic subtypes were correlated with response to doxorubicin versus docetaxel. Among the 204 evaluable patients, significant predictors of sensitivity in multivariate analysis were low topo2a expression and ER-negative status for doxorubicin and small tumor size and ER-negative status for docetaxel. Predictors of resistance in multivariate analysis were triple-negative status (ER/PgR/HER2 negative by IHC/FISH) for doxorubicin, and high TNM stage for docetaxel. Triple-negative tumors were associated with topo2a overexpression more than the other subtypes. In 94 patients with gene expression profiles, docetaxel was superior to doxorubicin in the basal-like subtype (good pathological response rate - PCR + class I of 56 vs. 0%; P = 0.034); no significant differences were observed in the other subtypes when comparing these two drugs. Low topo2a expression and ER-negative status were predictors of response to doxorubicin, while small tumor size and ER-negative status predicted response to docetaxel. Docetaxel was superior to doxorubicin in triple-negative/basal-like tumors, while no significant differences were seen in the remaining intrinsic subtypes.

Healthcare-associated infective endocarditis: an undesirable effect of healthcare universalization

Invasive medical technology has led to an increase in the incidence of healthcare-associated infective endocarditis (HAIE). A prospective multicentre cohort study was conducted at seven hospitals in Andalusia, Spain, to establish the characteristics of HAIE and to compare them with those of community-acquired infective endocarditis (CAIE). HAIE was defined as either infective endocarditis (IE) manifesting >48 h after admission to hospital, or IE associated with a significant invasive procedure performed in the 6 months before diagnosis. Seven hundred and ninety-three cases of IE were investigated, and HAIE accounted for 127 (16%). As compared with patients with CAIE, patients with HAIE were older (60.1 ± 14.4 years vs. 53.6 ± 17.5 years) and had more comorbidities (Charlson index 3.3 ± 2.3 vs. 1.8 ± 2.3) and staphylococcal infections (58.3% vs. 24.8%). Vascular manipulation was the main cause of bacteraemia responsible for HAIE (63%). Peripheral vein catheter-associated bacteraemia accounted for 32.8% of the catheter-related bacteraemias. In-hospital mortality (44.9% vs. 24.2%) was higher in the HAIE group. Septic shock (OR 2.2, 95% CI 2.9-30.2) and surgery not performed because of high surgical risk (OR 1.6, 95% CI 1.2-20) were independent predictors of mortality in HAIE. The present study demonstrates that HAIE is a growing health problem associated with high mortality. Careful management of vascular devices is essential to minimize the risk of bacteraemias leading to HAIE.

Very low prevalence and no clinical significance of occult hepatitis B in a cohort of HIV-infected patients with isolated anti-HBc seropositivity: the BHOI study

PURPOSE

Data on occult HBV infection in HIV patients are conflicting. We aimed to analyse the prevalence and clinical significance of occult hepatitis B in HIV-infected subjects.

METHOD

An open-label, cross-sectional, multicentre study including all subjects with isolated anti-HBc seropositivity from a cohort of 3,030 HIV-infected patients was undertaken. HBsAg and HBsAb were both negative in all cases, and those patients with acute or convalescent hepatitis B were excluded. HBV DNA was quantified by PCR with a detection limit of 20 IU/mL.

RESULTS

We found 5 cases (2.5%) of occult hepatitis B among 202 HIV-patients with isolated anti-HBc. The mean HBV DNA was 66 (15-112) IU/mL, none had symptomatic hepatitis, and their features, including aminotransferase levels, were similar to those without occult HBV infection.

CONCLUSIONS

Occult hepatitis due to HBV is very unusual in HIV-positive patients with isolated anti-HBc. The use of standard regimens of HAART including drugs with activity against HBV might underestimate the prevalence of occult HBV infection. These patients had a very low viral load, no identifiable risk factors, and no greater risk of hypertransaminasaemia or the development of symptomatic hepatitis.

Extraperitoneal laparoscopic para-aortic lymphadenectomy for lymph node recurrence of fallopian tube carcinoma

The endoscopic retroperitoneal approach is a minimally invasive method for surgical staging of cervical cancer. A 57-year-old woman had an intraoperative diagnosis of carcinoma of the left fallopian tube and undergone a retroperitoneal pelvic and para-aortic lymphadenectomy with no peritonization during surgical staging. Small suspicious nodes in the serous membrane of the sigmoid colon and peritoneal washings were positive for malignancy. A total of 12 nodes were obtained, all of which were negative. She received six cycles of paclitaxel and platinum-based chemotherapy and showed a complete clinical response. Thirty-two months after surgery, the abdominal computed tomography scan showed a left para-aortic lymph node, 19 mm in diameter, which was successfully removed through an extraperitoneal laparoscopic approach. The extraperitoneal laparoscopic approach of the para-aortic region is a feasible procedure after previous transperitoneal lymphadenectomy and chemotherapy.

[Antenatal care in immigrants]

The phenomenon of immigration has had an impact on the health care of the population. The immigrant population in Spain today represents approximately 8% of the total population. The majority of this population proceeds from countries with low income, and its origin and distribution is diverse. The immigrant population is characterised by its being young and healthy, and with a capacity to adapt to changes, but its social, economic and labour conditions are frequently insecure and favour vulnerability to disease. In spite of the number of immigrants of the male sex being globally higher than that of women, the percentage of immigrants of the female sex is growing. This increase of the female immigrant population has resulted in the appearance of specific health care needs, especially with respect to sexual and reproductive health. To which we must add a substantial increase in pathologies prevalent in the countries of origin, such as anaemia, tuberculosis, malnutrition, haemoglobinopathies, consanguinity, hypocalcaemia, hepatitis B and/or C, sexually transmitted infections, infectious diseases transmitted by arthropods, such as Chagas disease and other parasitoses, as well as genital mutilations. The aim of this article is to analyse the factors that make it difficult to control gestation in the immigrant population, as well as to establish guidelines for acting in antenatal care consultations. Insistence is placed on health education and prevention during pregnancy, and consideration is given to the appearance of rare diseases related to some of these groups.

Neonatal tumors of the CNS: a report of 9 cases and a review

Neonatal central nervous system (CNS) tumors are an uncommon and histologically heterogeneous group of neoplasms with different clinical and biological features from those arising in childhood. We report 9 cases in which a diagnosis of CNS tumor was confirmed by biopsy or autopsy during the years 1982-1997 in the Vall d'Hebrón Children's Hospital, Barcelona. Two cases were fetal tumors detected by fetal sonography, 3 patients were symptomatic in the first days after birth and 4 patients presented initial clinical signs in the first weeks or months of life. Eight lesions were supratentorial and 1 was located in the spinal cord. According to histologic types, there were 2 glioneuronal tumors, 1 anaplastic astrocytoma, 1 choroid plexus carcinoma, 1 immature teratoma, 1 craniopharyngioma, 1 hemangioblastoma, 1 astroblastoma and 1 hemangioendothelioma. Extensive review of the literature indicates that our cases of hemangioblastoma, astroblastoma and hemangioendothelioma are exceptional and one more of the very rare and isolated previously published cases.

Using lower eyelid fascial slings for recalcitrant burn ectropion

Burns of the lower eyelid represent a difficult management problem. Even with skin grafting, scarring and contraction can result in ectropion. This condition creates a marked aesthetic deformity, poses a risk of corneal exposure, and jeopardizes the patient's vision. Historically, full-thickness skin grafts and tarsorrhaphies have been described to manage recurrent ectropion. The lower eyelid fascial sling (LEFS) uses a temporalis fascial strip to create a suspension sling for the lower eyelid. In a series of 7 patients, the LEFS procedure resolved the symptoms permanently in all patients. Because the LEFS procedure counteracts the natural scar contraction forces of lower eyelid burns, it can resolve recalcitrant ectropion successfully while preserving the function and aesthetics of the lower eyelid.

DNA breakage detection-FISH (DBD-FISH) in human spermatozoa: technical variants evidence different structural features

Non-irradiated and X-irradiated (80 Gy) human spermatozoa were processed for in situ DNA breakage detection-FISH (DBD-FISH) of the whole genome, following two alternative variations of the basic technique. In the first, cells were initially incubated in the alkaline unwinding solution for transformation of DNA breaks into single-stranded DNA (ssDNA) to be hybridized, followed by the lysing solutions for protein removal. In the second, incubation in the lysing solutions was carried out before the denaturation step. The first approach yielded two subpopulations. While most sperm nuclei were faintly labeled and had chromocenters, a small subpopulation was strongly and homogeneously labeled, due to extensive DNA breakage. X-ray exposure increased the surface and mean fluorescence intensity. Otherwise, when the denaturation step was performed after protein extraction, all sperm nuclei yielded strong and dispersed FISH signals. Protein removal allows access of the unwinding solution to the DNA, which has abundant alkali-labile sites, and thus gives rise to large areas of ssDNA that are labeled by FISH. X-ray exposure increased the dispersion of FISH signals but decreased their mean fluorescence intensity. A linear dose-response was generated using the second experimental variant, being 30 Gy the lowest dose for detecting induction of damage by X-rays in mature sperm chromatin. These results indicate that DBD-FISH is not only useful for in situ detection of DNA breakage but also for revealing structural features of chromatin.

DNA breakage detection-fish (DBD-FISH): effect of unwinding time

DBD-FISH is a new procedure that allows detection and quantification of DNA breakage in situ within specific DNA target sites. Cells embedded in an agarose matrix on a slide are treated in an alkaline unwinding solution to transform DNA breaks into single-stranded DNA (ssDNA). After removal of proteins, DNA probes are hybridized and detected. DNA breaks increase the ssDNA and relax supercoiling of DNA loops, so more probe hybridizes, thereby increasing the surface area and fluorescence intensity of the FISH signal. The probe selects the chromatin area to be analysed. In order to restrict the extension of unwound ssDNA to a region closer to the origin of the DNA break, human leukocytes were processed for DBD-FISH with a whole genome probe, after a 10 Gy dose of X-rays, for various unwinding times: 5, 2 min and 30s. Two cell populations were detected after 30s, but not with the 5 or 2 min unwinding times. One cell group had small to medium haloes corresponding to the relaxation of DNA supercoiling after DAPI staining, and strong DBD-FISH labelling of induced DNA breaks, whereas the other cell group showed big haloes of DNA loop unfolding and an absence of DBD-FISH labelling. The latter group was similar to cells processed by DBD-FISH without the unwinding step. Thus, they should correspond to cells unaffected by the alkaline unwinding solution, possibly because very brief unwinding times do not allow the diffusion of the alkali into the cells deep within the gel, thus biasing the results. Taking this into account, 2 min seems to be the minimum unwinding time required for an accurate detection of a signal by DBD-FISH.

[The CNS amyloid]

INTRODUCTION

In this article we wish to review the most relevant pathogenic aspects and histological characteristics of the deposition of amyloid in the central nervous system (CNS).

DEVELOPMENT

The beta A4, a product of protein APP, codified on chromosome 21, is related to sporadic cerebral amyloid angiopathy not associated with dementia, Alzheimer's disease, senile dementia of Alzheimer type or Down's syndrome, whilst a specific mutation on the 693 codon of the gene which codifies beta-APP is related to hereditary haemorrhage with Dutch-type amyloid angiopathy. The gene which codifies cystatin C, a member of the family of cystatin genes grouped on chromosome 20p11.2, undergoes specific mutation giving rise to a mutant protein which, at the position 68, substitutes leucine for glutamine. The mutant cystatin C has a greater tendency to aggregation when the temperature is increased. This pathogenic molecular mechanism underlies cases of amyloidosis due to hereditary type cystatin C, considered to be a systemic amylosidosis. The formation and deposition of amyloid may also occur in other neurodegenerative diseases of animals and humans in relation to the accumulation of abnormal isoforms of the prion protein, especially in Gerstman-Straussler-Scheinke's disease and the Japanese type of prion cerebral amyloid angiopathy. The fact that these aberrant isoforms mostly undergo conformational changes involving a shift from alpha-helix to beta-sheet structure is basic to the amyloidogenesis of prion disease.

CONCLUSIONS

Amyloid is a family of proteins which is physically, chemically and structurally related, with common histochemical characteristics. In the CNS it is deposited in the vessel walls and parenchyma with topographic patterns and morphological differences according to the different disorders in which the amyloid is involved. Only neuropathological studies will enable us to discover its true incidence in senility with or without clinical features of dementia, and with or without haemorrhagic changes.

Levels of HBV-DNA and HBsAg after acute liver allograft rejection treatment by corticoids and OKT3

The aim of this work was to analyze whether the treatment of acute rejection of orthotopic liver transplants (OLT), either with corticoids or OKT3, has any effect on the levels of hepatitis B virus (HBV)-DNA and HBsAg in individuals which were originally affected by cirrhosis or fulminant hepatic failure as a result of B virus. We have found that HBV-DNA is present in macrophages, B cells and both CD4+ and CD8+ T cells after OLT in all cases studied. Interestingly, the levels of HBV-DNA and HBsAg in the serum analyzed were increased extremely rapidly in the patients treated with OKT3 in an acute rejection episode. However, the serum levels of HBV-DNA and HBsAg found were lower when the patients were treated with steroids, and were not found in non-treated patients. As the serum levels of HBV-DNA increase, the process of liver reinfection could be accelerated; therefore, these results may help to understand how OKT3 and corticoids immunosuppressive therapy may accelerate the reinfection of OLT by HBV. In conclusion, our results suggest that special care must be taken in the use of OKT3 in the treatment of acute liver rejection episodes in chronic or fulminant HBV transplanted patients.

A PCR product derived from female DNA with regional localization on the Y chromosome

A 154-bp PCR product amplified from human female DNA mapped onto the Y chromosome under high-stringency in situ hybridization conditions. The female DNA sequence revealed an 89% homology with the HSDYZ1 sequence. When the same primers were used to amplify male DNA, a 154-bp DNA fragment was also obtained, showing a 98% homology with HSDYZ1. However, although the HSDYZ1 sequence is widely distributed along the long arm of the Y chromosome, both of these particular PCR products are di-regionally localized within this distal block of constitutive heterochromatin. In situ hybridization under lower stringency showed that these 154-bp sequences map both onto the autosomes and the Y chromosome. Overall, this paper shows (i) a new class of DNA sequences shared by the autosomes and the Y chromosome; and (ii) a substructured organization of some DNA repeats within the DYZ1 family that forms a large part of the constitutive heterochromatin of the Y chromosome.

The efficacy and tolerability of venlafaxine and paroxetine in outpatients with depressive disorder or dysthymia

A 24-week, double-blind, randomized trial was performed to compare the efficacy and tolerability of venlafaxine and paroxetine in patients with major depression or dysthymia. Outpatients aged 18-70 years with a baseline score of 17 on the 21-item Hamilton Depression Rating Scale (HAM-D) were eligible. Patients were randomly assigned to venlafaxine, 37.5 mg, in the morning and evening or paroxetine, 20 mg, in the morning and placebo in the evening, which could be increased to venlafaxine, 75 mg twice daily, or paroxetine, 20 mg twice daily, after 4 weeks. Efficacy was assessed with the 21-item HAM-D, the Montgomery-Asberg Rating Scale, the Hamilton Anxiety Rating Scale, and the Clinical Global Impressions Scale. Forty-one patients were randomized to venlafaxine and 43 to paroxetine. At week 6, a response was observed in 55% of patients on venlafaxine and 29% on paroxetine (P = 0.03). At week 12, significantly (P = 0.011) more patients in the venlafaxine group had a HAM-D remission score of 8 or less (59% versus 31%). Discontinuation for any reason occurred in 16 (39%) patients on venlafaxine and 11 (26%) on paroxetine. The most common adverse events were nausea (28%), headache (18%) and dry mouth (15%) with venlafaxine and headache (40%) and constipation (16%) with paroxetine. Venlafaxine was effective and well tolerated for the treatment of patients with mild to moderate depression or dysthymia. A consistently higher proportion of patients had a response or remission on venlafaxine than on paroxetine.

[Stent implantation in palliative central aortopulmonary shunt of congenital cardiopathies with pulmonary hypoperfusion. Experience of 2 cases]

We describe the pioneer experience of balloon angioplasty and stent implantation in the central polytetrafluoroethylene aorto-pulmonary shunt. Two infants 1 and 13 month-old, with cyanotic complex congenital cardiopathy and pulmonary hypoperfusion, presented signs of prosthesis dysfunction with severe and critic hypoxemia. The angioplasty and stent implantation were performed through retrograde femoral arterial approach and "freely" (without a guide catheter) in the first case and venous via by using Judkins right coronary guiding catheter in the second one. Both cases experienced sustained O2 saturation improvement, although the neonate died on the fifth post-procedure day clue to acute renal failure. The postmortem anatomical findings are shown.

Chimerism quantification after sex-matched BMT: how probable is it to find donor/recipient pairs with distinguishable cells?

Chimerism quantification (CQ) after sex-matched bone marrow transplantation (BMT) is based on the identification of autosomal differences distinguishable at the chromosomal level, such as variations within constitutive heterochromatin between the recipient and the donor. The probability of finding distinguishable recipient/donor pairs at the karyotypic level depends on the frequency of the chromosome variants or morphs in the population, on whether recipient and donor are related, and if so, their kinship relation. We have developed a population genetics-based method that allows the estimation of the percentage of post-BMT CQ expected to be informative using any autosomal polymorphic marker. This method has been developed for the most common transplant situations, such as sibling-matched recipient/donor pairs, haploidentical related (parental/filial) pairs, and unrelated pairs. The method developed was applied to a polymorphism of the pericentromeric region of chromosome 3. This polymorphism becomes evident after in situ digestion with the restriction endonuclease Sau3A, and can be successfully used for CQ. It has been estimated that approximately 59% of the cases of BMT from unrelated donors, 36% of those from sibling donors, and 42% from parental/filial donors, are expected to be distinguishable for post-BMT CQ using this approach.

Hepatitis B immunization programme: Spain

Until the early 1990s, the hepatitis B prevention strategy in Spain was based exclusively on selective vaccination of high-risk groups. However, this strategy proved inadequate in reducing the incidence of disease and the prevalence rate of chronic carriers. In October 1991, the Autonomous Region of Catalonia embarked on a programme of universal immunization targeted at 12-year-olds. A few months later, in June 1992, the National Council on Health issued the recommendation that the "autonomous regions, taking into account their budgets and infrastructures, should establish HB immunization programmes for adolescents as soon as possible". Currently, the 17 autonomous regions are carrying out adolescent immunization programmes against HB.

A simplified technique of otoplasty: the temporary Kaye suture

The prominent or lop ear is often characterized by the absence of the antihelical fold. Various methods have been described to correct the deformity. Many involve placement of permanent sutures to reform the cartilage into the proper shape to correct the deformity. Marking the antihelical fold on the cartilage can be difficult and time-consuming when performing an otoplasty. By placing several percutaneous stay sutures from the anterior we are able to adjust the level of fold finely on the antihelix. We describe a technique that is simple, quick, and precise.

Complete digital duplication: a case report and review of ulnar polydactyly

An unusual case is presented of bilateral, complete digital duplication on the hand of a 9-month-old boy. Radiographic evaluation showed duplication of intact phalanges and metacarpals. Although ulnar polydactyly has been described as one of the most common congenital anomalies of the extremities, it usually manifests itself as a rudimentary skin tag. Ulnar polydactyly can be classified on the basis of genetic, morphologic, and clinical implications. Although polydactyly is reported to occur among approximately 1 in 1000 live births, most of these malformations are rudimentary skin tags. Complete ulnar polydactyly is uncommon; it occurs among approximately 0.014% of all live births. The main goal of surgical treatment of patients with complete-duplication ulnar polydactyly is to establish adequate function. This case report describes the preoperative evaluation and management of complete bilateral duplication of the ulnar digits of the hand.

[Comparative study of soluble interleukin 2 receptor and adenosine deaminase levels in tuberculous and other etiologies pleural fluids]

In order to better understand the immunological mechanisms involved in host protection against Mycobacterium tuberculosis infection, we studied soluble interleukin 2 receptor (sIL-2R) concentration in tuberculous pleural exudates as well as in pleural fluids of non-mycobacterial etiology. We collected pleural fluid from 40 patients: 10 with tuberculous bacterial pneumonia and 10 with trasudate. Soluble IL-2R was measured in the stored specimens using a standard ELISA technique. In patients with tuberculosis, sIL-2R in pleural fluid was 14,666 +/- 5,634 U/ml, significantly higher than was detected in any other group, being 4,341 +/- 2,655 U/ml in pneumonic exudates, 5,542 +/- 3,682 U/ml in neoplastic exudates and 1,377 +/- 125 in trasudates (p < 0.001). Also, an excellent correlation was demonstrated between adenosine-desaminase (ADA) and sIL-2R in tuberculous pleural fluids, with p < 0.001 and r = 0.805. In pleuropulmonary tuberculosis, compartmentalization of the immune response in the pleural space is responsible for the significantly higher levels of sIL-2R that were found in tuberculous pleural liquids compared with the ones detected in other diseases. This observation, as well as the demonstration of a good correlation between sIL-2R and ADA, suggest the possible usefulness of this molecule as an additional marker in the differential diagnosis of pleural effusions, though in the present study it appears to be less reliable than ADA.

[Value of a short (7 days) prophylactic course of ganciclovir in the prevention of cytomegalovirus disease after heart transplantation]

BACKGROUND

The incidence of cytomegalovirus disease remains important after heart transplantation, mainly in the first months after transplantation. We undertook a study to evaluate a short (7 days) prophylactic administration of ganciclovir to prevent cytomegalovirus disease after heart transplantation.

PATIENTS AND METHODS

There were two groups of patients: patients transplanted in 1993 (37) and patients transplanted in 1992 (38). In the first group, ganciclovir was given intravenously at a dose of 10 mg per kilogram of body weight every day from postoperative day 1 through day 7. In the second group, ganciclovir was not given. Similar regimens of immunosuppression (ATG, deflazacort, azathioprine and cyclosporine) were given.

RESULTS

Age, sex, serology in recipients and donors and incidence of acute rejection were comparable between both groups. Mortality was slightly higher in ganciclovir group (35%) than in control group (26%), although this difference was not statistically significant. There were two cases of cytomegalovirus disease in the ganciclovir group (6%) and nine cases in the control group (27%) (p < 0.05), all of them treated successfully. Cytomegalovirus disease in ganciclovir group occurred in two children, who were seronegative before transplantation. The incidence of cytomegalovirus disease in the pediatric recipients of ganciclovir group were 50% (2 of 4) and 100% in the control group (1 of 1). The incidence of cytomegalovirus disease were therefore 0% in the adult subgroup of ganciclovir group and 24% in the adult subgroup of control group.

CONCLUSIONS

A short (7 days) prophylactic administration of ganciclovir reduces the incidence of cytomegalovirus disease. In the pediatric group, the effectiveness is lower.

Patterns of DNase I sensitivity in the chromosomes of the grasshopper Chorthippus parallelus (Orthoptera)

We have analysed the patterns of DNase I/nick translation in the chromosomes of the grasshopper Chorthippus parallelus erythropus. Sites of preferential DNase I-nicking were concentrated at the distal chromosome regions, thus showing the non-uniform DNase I sensitivity of different chromosome domains. Among centromeric C-bands, the heterochromatin of metacentric and acrocentric chromosomes differed with respect to their DNase I resistance.

[Decrease in isoflurane requirements and of postoperative pain with preanesthetic intrathecal morphine]

OBJECTIVES

1) To determine whether preanesthetic intrathecal administration of 0.5 mg morphine reduces isoflurane requirements for anesthetic maintenance. 2) To assess the duration of postoperative analgesia and the type and frequency of complications attributable to the procedure.

PATIENTS AND METHODS

A series of 45 adults were distributed into 3 groups of 15 patients each based on site of surgery and site of preanesthetic (30 min) injection of 0.5 mg pure morphine. Control group (C0) patients underwent lumbar surgery and received subcutaneous morphine. Group C0.5 patients also underwent lumbar surgery but received intrathecal morphine. Group A0.5 patients underwent long-duration high abdominal surgery and received intrathecal morphine. Anesthesia was maintained with nitrous oxide (60%) in oxygen (40%) and a variable concentration of isoflurane. Isoflurane needs were assessed by averaging six consecutive measurements of end-tidal isoflurane pressure (M30FETiso) taken at intervals of 5 min. Postoperative analgesia was evaluated by means of a visual analog scale that was converted to numerical units (VASn).

RESULTS

M30FETiso in group C0 (0.8%) was always higher (p < 0.01) than in the other two groups. M30FETiso in group A0.5 was higher (p < 0.01) than in group C0.5 during the first 150 min of surgery. After 180 min, there were no differences in M30FETiso (0.10-0.16%) between the two groups receiving intrathecal morphine. VASn results (mean +/- SD) in the first 4 hours were higher in group C0 (7.33 +/- 0.6) than in group C0.5 (1.13 +/- 0.35) and group A0.5 (1.07 +/- 0.26). The time of morphine-dependent analgesia was shorter (p < 0.01) in group C0 (0.62 +/- 0.38 hours) than in groups C0.5 (30.4 +/- 5.11 hours) and A0.5 (28 +/- 4.34 hours). There were no significant differences between the two groups receiving intrathecal morphine.

CONCLUSIONS

Preanesthetic subarachnoid lumbar injection of 0.5 mg of pure morphine reduced early requirements for isoflurane in lumbar surgery (0.14% after 60 min). This reduction was initially less in patients undergoing abdominal surgery (0.44% at 60 min) but was the same after 150 min. Postoperative analgesia was long-term and independent of type or duration of surgery. There was no respiratory depression after surgery and the incidence of postoperative complications was similar in the two groups that received subarachnoid morphine.

Implementing universal vaccination programmes: Spain

Until 1990, the immunization policy against hepatitis B in Spain was selective high-risk vaccination. That policy failed to reduce the incidence of hepatitis B and the prevalence rates of chronic carriers. In 1991, Catalonia began a universal immunization programme targeted at 12-year-olds. Six other regions (Castilla-León, Valencia, Extramadura, Navarra, the Balearic Islands and Rioja) introduced vaccination programmes in 1992. In 1993, three more regions (Galicia, Castilla-La-Mancha and Pais Vasco) began immunizing young adolescents. This means that 12-year-olds in Spain are now included in vaccination programmes against hepatitis B.

The distribution of genes on chromosomes: a cytological approach

Studies during the last 20 years have shown that the chromosomes of many organisms, especially those of higher vertebrates, consist of a series of segments having different properties. These can be recognized as, for example, G- and R-bands. Recent studies have indicated that genes tend to lie in the R-bands rather than in the G-bands, although the number of genes that has been mapped with high precision is, as yet, only a very small proportion of the total, probably much less than 1%. We have therefore sought to study the distribution of genes on chromosomes using a cytological approach in conjunction with "universal" markers for genes. Such markers include mRNA and the gene-rich, G+C-rich H3 fraction of DNA, both of which can be localized using in situ hybridization, and DNase I hypersensitivity, and digestion by restriction enzymes known to show selectivity for the CpG islands associated with active genes, both of which can be detected using in situ nick translation. We have chosen to use the approaches involving in situ nick translation and have shown that the patterns of DNase I hypersensitivity and of CpG islands on human chromosomes show a strict correspondence to R-banding patterns: Deviations from R-banding patterns reported by previous investigators who have made similar studies appear to be attributable to excessive digestion.(ABSTRACT TRUNCATED AT 250 WORDS)

In situ nick translation of meiotic chromosomes to demonstrate homologous heterochromatin heterogeneity

The in situ nick translation procedure performed on fixed meiotic chromosomes partially cleaved with restriction endonucleases shows a different staining of homologous heterochromatic regions, which could be explained through a differential restriction endonuclease cleavage. Mutations occurring before massive tandem duplication and involving those DNA motifs that produce these heterochromatic blocks, together with the absence of DNA recombination that characterizes these particular regions, could explain the observed results. This method for chromosome labelling is most useful to demonstrate a certain level of heterochromatin heterogeneity that is present in the genome of living species but remained cryptic to other techniques that are also able to induce longitudinal differentiation of the chromosomes.Key words: cytogenetics, nick translation, meiosis, heterochromatin.