Natriuretic peptides: Another tool for the management of cancer?

The connection between heart failure (HF) and cancer through multiple pathways such as inflammation, oxidative stress, and neurohormonal activation, among others, is well established. As a consequence, increases in plasma levels of several biomarkers have been described in both disorders. The most consistent information is related to natriuretic peptides (NPs). Although they are known to be produced in the ventricles as a response to myocardial distension, and thus can be useful for the diagnosis and prognosis of HF, and also for the management of chemotherapy-induced myocardial damage, they are also produced by tumour cells. In this regard, increased plasma levels of NPs have been described in patients with multiple malignancies in the absence of volume overload. Natriuretic peptide levels have been shown to correlate directly with the extension of tumours and with poorer outcomes. Moreover, some data indicate that they may help in the detection of subclinical tumours. Given that these peptides have been described to have anti-proliferative and anti-angiogenic effects, a plausible hypothesis is that they may be produced by tumours as a negative feed-back mechanism to avoid tumour progression. This would lead to increased levels of NPs in plasma that could be potentially useful for early detection of malignancies as well as for a prognostic assessment. Nevertheless, since the sample size of many studies published so far is limited, more data are needed to provide consistent data in order to confirm or rule out this hypothesis.

Li-Fraumeni syndrome heterogeneity

Clinical variability is commonly seen in Li-Fraumeni syndrome. Phenotypic heterogeneity is present among different families affected by the same pathogenic variant in TP53 gene and among members of the same family. However, causes of this huge clinical spectrum have not been studied in depth. TP53 type mutation, polymorphic variants in TP53 gene or in TP53-related genes, copy number variations in particular regions, and/or epigenetic deregulation of TP53 expression might be responsible for clinical heterogeneity. In this review, recent advances in the understanding of genetic and epigenetic aspects influencing Li-Fraumeni phenotype are discussed.

Retinoblastoma: towards an earlier diagnosis

OBJECTIVES

The number of enucleations and visual sequels due to retinoblastoma is high. The aim of this study was to evaluate the different diagnostic aspects and propose strategies that might improve the clinical management of this condition.

METHOD

A retrospective study was conducted on 38 patients with retinoblastoma studied genetically (29 unilateral, 9 bilateral). The evaluation included: age of onset, clinical signs, and time since onset, number of enucleations, time to diagnosis, and survival at 5 years.

RESULTS

Leukocoria was the main clinical sign (present in 90% of cases). The mean diagnostic delay was 3.2 months. Among the unilateral cases, the eyes were enucleated in 76%, and 55% in the bilateral forms. Only one death was found among the 25 patients followed-up for at least 5 years.

CONCLUSIONS

Retinoblastoma diagnostic and treatment strategies need to be updated. Good coordination between paediatricians and ophthalmologists is essential for this. Its management in reference centres, which have the necessary technology and experience, should contribute to increase the rate of organ preservation.

[Parental presence in the operating room: effect on the quality of anesthetic induction and postoperative agitation in children]

BACKGROUND AND OBJECTIVE

Various nonpharmacologic strategies for reducing anxiety in children and improving cooperation during induction of anesthesia have been investigated. Parental presence during anesthetic induction has been the alternative studied most often, especially in English-speaking populations. Mixed results have been reported, however. The aim of this study was to evaluate the quality of anesthetic induction and the development of postoperative agitation in Spanish children undergoing ear, nose, or throat surgery with or without parental presence in the operating room.

PATIENTS AND METHODS

Children in American Society of Anesthesiologists class 1 or 2 who were scheduled for ear, nose or throat surgery under inhalation anesthesia were randomized to 2 groups for presence or absence of a parent in the operating room. The induction experience was classified as easy, carried out with moderate resistance, or traumatic. The postoperative period was assessed as easy or traumatic.

RESULTS

Forty children were randomized. Time to onset of anesthesia was similar in the 2 groups. Induction was easy for 65% of the children with parental presence and for 25% of the children without a parent present (P < .05). Induction was traumatic for 25% in the parental presence group and for 35% in the parental absence group (P < .05). The incidence of moderate resistance during induction was similar in the 2 groups; the quality of the postoperative experience was also similar.

CONCLUSIONS

Parental presence during induction of inhalation anesthesia improves the induction experience of nonpremeditated Spanish children, increasing the incidence of easy induction and decreasing the presence of traumatic induction. The quality of the postoperative experience is similar.

HIV/STI co-infection among men who have sex with men in Spain

In Spain, neither the HIV nor the STI national surveillance systems collect information on HIV/STI co-infection. However, there are two networks based on HIV/STI clinics which gather this data. We describe HIV prevalence in men who have sex with men (MSM) diagnosed with infectious syphilis and/or gonorrhoea in 15 STI clinics; and concurrent diagnoses of STI in MSM newly diagnosed with HIV in 19 HIV/STI clinics. In total, 572 MSM were diagnosed with infectious syphilis and 580 with gonorrhoea during 2005-2007. HIV prevalence among syphilis and gonorrhoea cases was 29.8% and 15.2% respectively. In the multivariate analysis, HIV/syphilis co-infection was associated with being Latin American; having a history of STI; reporting exclusively anal intercourse; and having sex with casual or several types of partners. HIV and gonorrhoea co-infection was associated with age older than 45 years; having no education or only primary education completed; and having a history of STI. In total, 1,462 HIV infections were newly diagnosed among MSM during 2003-2007. Of these, 31.0% were diagnosed with other STI at the same time. Factors associated with STI co-infection among new HIV cases in MSM were being Latin American; and having sex with casual partners or with both steady and casual partners. In Spain, a considerable proportion of MSM are co-infected with HIV and STI.

Subtelomeric analysis of pediatric astrocytoma: subchromosomal instability is a distinctive feature of pleomorphic xanthoastrocytoma

Astrocytic neoplasms are genetically heterogeneous; however a low frequency of genomic changes has been found in juvenile pilocytic astrocytoma (PA) in molecular studies. Concerning pleomorphic xanthoastrocytomas (PXA), recent studies have given heterogeneous results for chromosomal alterations. We studied the subtelomeric regions of 19 primary astrocytoma tumors. Results were near normality for the PA group with relative scarcity of chromosomal imbalances, except for the duplication of 3pter in 4/15 and deletion of 21qter in 5/15 of them. In contrast, a specific profile was observed in the 4 PXA tumoral samples. This involved 3pter, 14qter and 19pter duplication and 4qter, 6qter, 9qter, 13cen, 17pter, 18qter and 21qter deletion. Our results indicate that the chromosomal and genetic aberrations in PXAs differed from those typically associated with the diffusely infiltrating astrocytic and oligodendroglial gliomas. These genetic differences would likely contribute to the more favorable behavior of PXAs and may be helpful for molecular differential diagnosis of pediatric cerebral tumors.

Tumour banks in pediatric oncology

INTRODUCTION

The information offered by the new genomic and proteomic techniques will play a central role in our knowledge of cancer; but it is limited by the lack of available tissue samples. Cancer in children is a sum of infrequent diseases, so tumor banks are support tools for translational research, providing access to a sufficiently large series of samples, which would minimize the asymmetric effect of the diverse origin.

MATERIAL AND METHODS

From 2003 a Molecular Pathology Network in Pediatric Solid Tumors Netwoks exists in Spain, and we are a part of it. Our aim was to create a pediatric tumor bank program and consensus documents about its use.

RESULTS

Standard Operating Procedures for collection and transport of samples have been created.

CONCLUSIONS

Thinking about the fast progress in Molecular Biology and the low frequency in pediatric tumors, it is vital to consider the importance of a bio bank.

[Prevalence of the HIV infection in patients seen at specialized diagnosis centers in 9 cities in Spain from 1992 to 2001]

OBJECTIVE

To describe the prevalence of HIV infection in persons tested between 1992 and 2001.

DESIGN

Descriptive, cross-sectional epidemiological study.

SETTING

10 ambulatory centers specialized in diagnosing HIV, located in 9 cities in Spain.

PARTICIPANTS

53,183 persons older than 12 years, tested for the first time for HIV.

MAIN MEASURES

Number of persons tested per year, number of persons diagnosed as seropositive for HIV according to sex, age group and category of exposure.

RESULTS

The number of persons tested increased from 4401 in 1992 to 6407 in 2001. Approximately half reported heterosexual risk exposure/exposure through high-risk heterosexual behaviors, excluding prostitution. Intravenous drug users (IVDU) increased from 15.3% in 1992-1993 to 1.4% in 2000-2001, and women prostitutes/female sex workers increased from 6.7% to 25.1%. A total of 2898 persons were diagnosed as having HIV infection; 78% of them were men. The number of diagnoses decreased from a high of 1058 in 1992-1993 to 304 in 2000-2001, and this trend was seen for all categories of exposure except female prostitutes and men with heterosexual risk factors. The prevalence decreased from 14% in 1992 to 2% in 2001. There were decreases in all categories of exposure, especially during the first years of the study, with a tendency to level off. In 2001 the prevalence figures were 23.8% for IVDU, 7.9% for homosexual men and women, 0.8% for female sex workers and 1% for other heterosexual men and women.

CONCLUSIONS

The specialized diagnostic centers play an important role in diagnosing HIV, and this service complements primary care services. Greater efforts are needed in the prevention of HIV infection.

Noninvasive, near infrared spectroscopic-measured muscle pH and Po2 indicate tissue perfusion for cardiac surgical patients undergoing cardiopulmonary bypass*

OBJECTIVE

To determine whether near infrared spectroscopic measurement of tissue pH and Po2 has sufficient accuracy to assess variation in tissue perfusion resulting from changes in blood pressure and metabolic demand during cardiopulmonary bypass.

DESIGN

Prospective clinical study.

SETTING

Academic medical center.

SUBJECTS

Eighteen elective cardiac surgical patients.

INTERVENTION

Cardiac surgery under cardiopulmonary bypass.

MEASUREMENTS AND MAIN RESULTS

A near infrared spectroscopic fiber optic probe was placed over the hypothenar eminence. Reference Po2 and pH sensors were inserted in the abductor digiti minimi (V). Data were collected every 30 secs during surgery and for 6 hrs following cardiopulmonary bypass. Calibration equations developed from one third of the data were used with the remaining data to investigate sensitivity of the near infrared spectroscopic measurement to physiologic changes resulting from cardiopulmonary bypass. Near infrared spectroscopic and reference pH and Po2 measurements were compared for each subject using standard error of prediction. Near infrared spectroscopic pH and Po2 at baseline were compared with values during cardiopulmonary bypass just before rewarming commenced (hypotensive, hypothermic), after rewarming (hypotensive, normothermic) just before discontinuation of cardiopulmonary bypass, and at 6 hrs following cardiopulmonary bypass (normotensive, normothermic) using mixed-model analysis of variance. Near infrared spectroscopic pH and Po2 were well correlated with the invasive measurement of pH (R2 =.84) and Po2 (R 2 =.66) with an average standard error of prediction of 0.022 +/- 0.008 pH units and 6 +/- 3 mm Hg, respectively. The average difference between the invasive and near infrared spectroscopic measurement was near zero for both the pH and Po2 measurements. Near infrared spectroscopic Po2 significantly decreased 50% on initiation of cardiopulmonary bypass and remained depressed throughout the bypass and monitored intensive care period. Near infrared spectroscopic pH decreased significantly during cardiopulmonary bypass, decreased significantly during rewarming, and remained depressed 6 hrs after cardiopulmonary bypass. Diabetic patients responded differently than nondiabetic subjects to cardiopulmonary bypass, with lower muscle pH values (p =.02).

CONCLUSIONS

Near infrared spectroscopic-measured muscle pH and Po2 are sensitive to changes in tissue perfusion during cardiopulmonary bypass.

[HIV prevalence among homosexual and bisexual men in Spain, 1992-2000]

BACKGROUND

Our purpose was to describe the time trend in HIV seroprevalence among homo/ bisexual men.

SUBJECTS AND METHOD

We analyzed 9,383 homo/ bisexual men who had a first voluntary test for HIV in 10 Spanish clinics from 1992 to 2000.

RESULTS

HIV prevalence decreased from 20.3% in 1992 to 8.4% in 2000. In the multivariate analysis this decline appeared independently associated with the testing year and the birth cohort.

CONCLUSIONS

New generations of voluntarily tested homo/bisexual men are less infected by HIV, but it is yet necessary to intensify the prevention programs.

A retrospective study (1994-1999) of 441 ITI(r) implants in 114 patients followed-up during an average of 2.3 years

OBJECTIVE

Implantation is a common practice in the oral rehabilitation of edentulous patients, affording good results in extensive patient series. The aim was to determine the average success rate and analyze the causes of implant failure.

MATERIAL AND METHODS

In the present retrospective study (1994-1999) a total of 441 ITI(r) implants were performed in 114 patients (58 females (51%) and 56 males (49%) aged 44.5 years on average; range 12-82 years), with a mean follow-up of 2.3 1.3 years. Data recorded included patient age and sex, smoking habit, oral hygiene, the number, length, diameter and type of implants, their location and the prostheses fitted.

RESULTS

After 2.3 1.3 years of follow-up, the implant success rate was 96.2%. In 7 patients a total of 15 implants failed during the osseointegration period, while in two patients a total of two implants failed following dentures placement. The failures were mainly attributed to over-drilling during the surgical procedure, or to an overloading upon tightening in the osseointegration period. No significant relation was observed between implant loss and the rest of the clinical parameters studied, with the sole exception of implant length (failure increasing with shorter lengths)(chi-square; p = 0.001).

Sensitivity of the Doppler rate of pressure rise to changes in the inotropic state: an experimental comparison with invasively obtained dP/dt

AIMS

To investigate the sensitivity of the rate of pressure rise obtained by Doppler to changes in the inotropic state by comparing it to simultaneous invasive measurements of dP/dt under different conditions of contractility.

METHODS AND RESULTS

Mitral regurgitation was provoked in five pigs, and simultaneous measurements of dP/dt and the Doppler-estimated rate of pressure rise were made with a micro-manometer and with continuous-wave Doppler. Changes in the inotropic state were induced by drug infusion and by ischaemia. One hundred and twenty-seven simultaneous measurements were made with a correlation coefficient between the Doppler-estimated rate of pressure rise and dP/dt of 0.85 (P<0.001). Sensitivity to inotropic changes was estimated as the percentage change of each parameter in each condition of contractility, and showed that the Doppler-estimated rate of pressure rise had better sensitivity than dP/dt.

CONCLUSION

The sensitivity of Doppler-estimated rate of pressure rise to changes in the inotropic state is greater than that of dP/dt. The correlation between the rate of pressure rise obtained by Doppler and dP/dt is maintained even in extreme conditions of contractility. Therefore, the rate of pressure rise can be considered a good parameter to assess linear changes of contractility.

[Ductus closure in adults with the Rashkind device: comparative results]

INTRODUCTION

Catheter occlusion of the persistent ductus arteriosus with Rashkind device is an alternative to the surgical closure demonstrated in children, however a few results have been reported of occlusion in adults.

METHOD

From 1990 to 1996 in 127 patients with persistent ductus arteriosus undergoing occlusion by Raskind device. Two groups according age: 105 children (< 14 years) and 22 adults (> 14 years), were studied retrospectively. The results were analysed by immediate aortogram and follow-up at 24 hours, 6 and 12 months by color-Doppler echocardiograms.

RESULTS

The adults were frequently asymptomatic (86%) and with high incidence (59%) of silent ductus. Similar QP/QS (1.61 +/- 0.47 in adults vs 1.49 +/- 0.51) was calculated although pulmonary pressure was superior in children (12.50 +/- 2.97 vs 16.84 +/- 5.88 mmHg; p = 0.003). In group > 14 years the ductal anatomy favorable (Krichenko type A or B) was more frequent (91% vs 73%; p = 0.06) and ductal diameter significantly higher (3.03 +/- 1.50 vs 2.41 +/- 0.96 mm; p = 0.009). In adults 17 mm umbrella were used more frequently (91 vs 61%; p = 0.02). Absence complications (embolization, bacteremia, haemolysis, proximal stenosis of the left pulmonary artery) were found in adults against 4.72% in children. The occlusion were more effective in adults specially in early controls: 55% vs 34% (p = 0.09), 82% vs 69%, 91% vs 77% and 95% vs 83% (p > 0.10). Multivariate analysis identified age as an independent predictor of complete occlusion.

CONCLUSION

Our experience in transcatheter occlusion of persistent ductus arteriosus with Rashkind device in adults support the efficacy, safety and excellent early results despite higher incidence of silent asymptomatic ductus.

[Intravenous leiomyomatosis with cardiac extension]

Intravenous leiomyomatosis is a very rare uterine neoplasm, characterized by histological benignity. In some cases, it could extend through the ovaric or iliac veins up to the vena cava and the right chambers of the heart. We report a patient with symptoms of right heart failure, who was diagnosed by transesophagic echocardiography of intravenous leiomyomatosis with extension to the right ventricle. Complete excision was achieved employing simultaneous sternotomy and laparotomy with echocardiographic intraoperative monitorization.

[Myocardial contusion with and without coronary artery involvement]

We present the first case of myocardial contusion secondary to blunt chest trauma with injury in two different areas, with and without coronary lesions. The akinesis of the anterolateral wall was secondary to the obstruction of the left anterior descending coronary artery and the severe hypokinesis of the posterior wall, without lesion of the right coronary artery, was probably related with the compression between the sternum and vertebral column.

Diagnostic value of two-dimensional echocardiography in cardiac hydatid disease

Echinococcal infection of the heart is rare. The preoperative findings, with special attention to two-dimensional echocardiography (2DE), of six patients with cardiac echinococcosis and their surgical and pathological correlations are reported. Cardiac hydatid cysts (HCs) were located in the cardiac apex in three patients, in the upper part of the interventricular septum extending towards the anterior aspect of the heart in one and in the postero-superior right atrial wall in another patient. The remaining patient had multiple intrapericardial cysts. In three patients the cysts presented as well defined, rounded, echolucent masses within the myocardial wall bulging into the cardiac chambers. In two patients, the cysts had ruptured into a cardiac chamber with loss of the characteristic 'cystic' appearance; these cysts presented as an echogenic or solid mass protruding into a cardiac chamber. Finally, another patient had one HC with echolucent appearance and another HC in a different location with echogenic appearance; this last cyst corresponded to a degenerated HC. In two cases the cyst showed a loculated internal aspect. In one patient the myocardial segment involved by the cyst had a dyskinetic movement. In all six patients, 2DE accurately demonstrated the location and morphological details of the cardiac cysts, permitted recognition of the ruptured and/or degenerated cysts and was superior to thoracic computed tomography and angiography in the preoperative assessment of these patients. Nuclear magnetic resonance imaging (one patient) gave no further information to that obtained by 2DE. We conclude that 2DE is the technique of choice for an early diagnosis of this rare entity.

[Massive myocardial infiltration by lymphoma of tonsilar origin simulating left ventricular hypertrophy: diagnosis using echocardiography]

We present the first described case in the literature of isolated left anterior hemiblock, in the setting of massive myocardial invasion by a primary tonsilar lymphoma. Such process evolved with a morphologic pattern mimicking left ventricular hypertrophy of unequal distribution. An hemodynamic behaviour of an infiltrative cardiomyopathy, with both systolic and diastolic important ventricular dysfunction, was observed. An early presumptive diagnosis of severe lymphomatous myocardial invasion was established by echocardiography. The pathologic examination confirmed it subsequently.