Housing and health: a collaborative project for evidence-based policy-making

Issue

The potential to improve health and equity through better housing is well established. However, housing policies (mainly focused on energy efficiency) have not fully integrated health.

Description

Within the Urban Environment and Health Project of the Diputació de Barcelona, their Housing and Public Health Offices and the Barcelona Institute for Global Health undertook the first phase (May-December 2020) of a collaborative project on housing and health. Focused on the physical dwelling, a map of health risk factors (linked to thermal comfort, environmental and spatial quality), a literature review of each factor, and a list of local health-promoting housing programs were elaborated. Issues addressed included: (a) most relevant home factors affecting health; (b) evidence of poor housing conditions impacting physical, mental, and social health of residents; (c) housing improvements with documented positive health benefits. The second phase (March-December 2021) uses the same methods to address two new housing dimensions: residential environment and community.

Results

Recent research on housing and health explores the potential accumulative/synergistic effects of combined exposures, as additional poor housing parameters (e.g. low indoor air quality, lack of natural light, pest problems, material damage) correlate with poorer health status and higher use of medical resources. Through this collaborative project, increased awareness among local officers has led to preliminary context-specific criteria and parameters to promote healthy homes beyond compliance with current building codes, especially aimed at increasing maintenance and renovation standards in older neighborhoods of Barcelona.

Lessons

Collaboration between stakeholders allows for rich and innovative perspectives and encourages multisectoral actions. Context-specific health costs/benefits analyses are needed to facilitate development and implementation of housing policies with health at its core.

Key messages

Housing policies should have a holistic approach of health risks, redounding in housing policies improvement. Collaborative projects between academic institutions and local governments encourage pivotal evidence-based housing policy-making.

OP0004 AUTOIMMUNE AND INFLAMMATORY MANIFESTATIONS IN COMMON VARIABLE IMMUNODEFICIENCY DISORDERS

Background:

Common variable immunodeficiency (CVID) disorders are the second most frequent immunodeficiency worldwide and autoimmune diseases (AD) are present in 20% of such patients, cytopenia being the most frequent manifestation [1]. Defects in central and peripheral tolerance, activation/proliferation of B cells, and hypogammaglobulinemia are key features of the disease, along with a reduction in CD4+T cells, abnormalities in Treg and defective secretion of regulatory cytokines, that could perpetuate autoimmune - autoinflammatory phenomena.

Objectives:

To describe immune and inflammatory disorders in our CVID cohort.

Methods:

Retrospective analysis of 33 patients who fulfill the European Society for Immunodeficiencies (ESID) Registry – Work criteria for CVID diagnosis [2] treated in the immunodeficiency unit of our tertiary university hospital. After getting an informed consent form, medical records were revised to obtain clinical, analytical and immunological data.

Results:

Of the 33 CVID patients analysed, 11 had some autoimmune/inflammatory manifestation. Seven patients presented autoimmune thrombocytopenia (AIT), and one of them also had non-severe neutropenia. Two patients also had seronegative spondyloarthropathy, one patient had cutaneous psoriasis, and two patients had alopecia. There were no cases of type 1 diabetes, vitiligo or thyroid disorders. Interestingly, four patients had lung involvement, two of them with granulomatous-lymphocytic interstitial lung disease (GLILD), one with organising pneumonia and one with usual interstitial pneumonia. Five of the eleven patients required immunosuppressive treatment, mostly with steroids. One case of AIT required concomitant treatment with azathioprine and the patient with psoriasis was treated with methotrexate. In six patients, autoimmune disorder was the first manifestation.

Conclusion:

33% of the CVID patients had autoimmune or inflammatory manifestations in our cohort; six patients had one immune/inflammatory phenomena, four had two different disorders and one patient presented with three different ones. The most frequent manifestation was AIT, as seen in previous reports. In six cases, the autoimmune-inflammatory manifestation was the first symptom attributable to CVID. In conclusion, AD are common in CVID patients, so clinicians must be aware of possible immunodeficiencies in this type of patients.

References:

[1]Amaya-Uribe L, Rojas M, Azizi G, Anaya JM, Gershwin ME. Primary immunodeficiency and autoimmunity: A comprehensive review. J Autoimmun. 2019 May;99:52-72.

[2]ESID Registry – Working Definitions for Clinical Diagnosis of PID, January 22, 2019.

Disclosure of Interests:

None declared

Molecular Assessment of Microcirculation Injury in Formalin-Fixed Human Cardiac Allograft Biopsies With Antibody-Mediated Rejection

Precise diagnosis of antibody-mediated rejection (AMR) in cardiac allograft endomyocardial biopsies (EMBs) remains challenging. This study assessed molecular diagnostics in human EMBs with AMR. A set of 34 endothelial, natural killer cell and inflammatory genes was quantified in 106 formalin-fixed, paraffin-embedded EMBs classified according to 2013 International Society for Heart and Lung Transplantation (ISHLT) criteria. The gene set expression was compared between ISHLT diagnoses and correlated with donor-specific antibody (DSA), endothelial injury by electron microscopy (EM) and prognosis. Findings were validated in an independent set of 57 EMBs. In the training set (n = 106), AMR cases (n = 70) showed higher gene set expression than acute cellular rejection (ACR; n = 21, p < 0.001) and controls (n = 15, p < 0.0001). Anti-HLA DSA positivity was associated with higher gene set expression (p = 0.01). Endothelial injury by electron microscopy strongly correlated with gene set expression, specifically in AMR cases (r = 0.62, p = 0.002). Receiver operating characteristic curve analysis for diagnosing AMR showed greater accuracy with gene set expression (area under the curve [AUC] = 79.88) than with DSA (AUC = 70.47) and C4d (AUC = 70.71). In AMR patients (n = 17) with sequential biopsies, increasing gene set expression was associated with inferior prognosis (p = 0.034). These findings were confirmed in the validation set. In conclusion, biopsy-based molecular assessment of antibody-mediated microcirculation injury has the potential to improve diagnosis of AMR in human cardiac transplants.

Molecular diagnosis of T cell-mediated rejection in human kidney transplant biopsies

Histologic diagnosis of T cell-mediated rejection is flawed by subjective assessments, nonspecific lesions and arbitrary rules. This study developed a molecular test for T cell-mediated rejection. We used microarray results from 403 kidney transplant biopsies to derive a classifier assigning T cell-mediated rejection scores to all biopsies, and compared these with histologic assessments. The score correlated with histologic lesions of T cell-mediated rejection (infiltrate, tubulitis). The accuracy of the classifier for the histology diagnoses was 89%. Very high and low molecular scores corresponded with unanimity among three pathologists on the presence or absence of T cell-mediated rejection, respectively. The molecular score had low sensitivity (50%) and positive predictive value (62%) for the histology diagnoses. However, histology showed similar disagreement between pathologists--only 45-56% sensitivity of one pathologist with diagnoses of T cell-mediated rejection by another. Discrepancies between molecular scores and histology were mostly when histology was ambiguous ("borderline") or unreliable, e.g. in cases with scarring or inflammation induced by tissue injury. Vasculitis (isolated v-lesion TCMR) was particularly discrepant, with most cases exhibiting low TCMR scores. We propose new rules to integrate molecular tests and histology into a precision diagnostic system that can reduce errors, ambiguity and interpathologist disagreement.

A new diagnostic algorithm for antibody-mediated microcirculation inflammation in kidney transplants

We studied the significance of microcirculation inflammation in kidney transplants, including 329 indication biopsies from 251 renal allograft recipients, who were mostly nonpresensitized (crossmatch negative). Glomerulitis (g) and peritubular capillaritis (ptc) were often associated with antibody-mediated rejection (65% and 75%, respectively), but were also found in other diseases in the absence of donor-specific antibody (DSA): T-cell-mediated rejection (ptc, g), glomerulonephritis (g) and acute tubular necrosis (ptc). To develop rules for reducing the nonspecificity of microcirculation inflammation and defining the best grading thresholds associated with DSA, we built and validated a decision tree to predict DSA. The decision tree revealed that g + ptc sum (addition of g-score plus ptc-score) was the best predictor of DSA, followed by time posttransplant, then C4d, which had a small role. Late biopsies with g + ptc > 0 showed higher frequency of DSA compared to early biopsies with g + ptc > 0 (79% vs. 27%). Microcirculation inflammation in early biopsies was often false positive (antibody-independent). The decision tree predicted DSA with higher sensitivity and accuracy than C4d staining. Microcirculation inflammation sum score predicted graft failure independently of time, C4d and transplant glomerulopathy. Thus any degree of microcirculation inflammation in late kidney transplant biopsies strongly indicates presence of DSA and predicts progression to graft failure.

The B-Lynch technique for the management of intraoperative uterine atony

This paper reports the experience of 150 B-Lynch suture applications for the management of uterine atony during caesarean section that did not respond to conventional therapeutical measures. Technique was considered effective if the need for hysterectomy was avoided. High-risk antenatal obstetrical conditions included: pre-eclampsia (12%), oligohydramnios (8%), polyhydramnios (4.7%). A total of 36% were primigravid, 66% had been in active labour, 4.7% received misoprostol and 26.7% used oxytocin for labour augmentation. Suture was successful in 95.3%, with only five cases requiring hysterectomy combined with uterine artery ligation and two uterine artery ligations alone to control bleeding and uterine atony ('floppiness'). Although 26.7% of cases required transfusions, no maternal deaths were reported, and overall women were discharged after a median 4-day hospital stay without further complications upon follow-up. The B-Lynch technique was an effective intraoperative measure to control uterine atony. Despite the encouraging results, long term assessment on a larger sample is needed in our clinical scenario.

[Management of distal ureter in laparoscopic nephroureterectomy]

INTRODUCTION

Nephroureterectomy is one of the procedures for which a laparoscopic approach is more clearly indicated. However, despite the long experience available, management of the distal ureter is still difficult.

MATERIALS AND METHODS

Thirty-two laparoscopic nephroureterectomies were performed from November 2004 to December 2008. The procedure used was endoscopic resection of distal ureter and earlier ligation of the ureter in the laparoscopic time in 13 patients, a laparoscopic bladder cuff in 13 patients, and an open bladder cuff in 3 patients.

RESULTS

Mean operating time was 221.53 min (125-315 min), and mean postoperative stay of 27 patients was 4.6 days. Conversion to open surgery and discontinuation of the procedure for local tumor progression were required in one patient each. Mean patient follow-up was 17.8 months. No local relapse or metastasis occurred in the ports.

CONCLUSION

The most common procedures continue to be endoscopic resection and the open bladder cuff depending on indication. Any laparoscopic approach to upper urothelial tumors must strictly comply with oncological principles. The reported procedure is in our experience the fastest, most simple, and most effective for this purpose. In our opinion, the therapeutic algorithm provided is adequate for management of the distal ureter in laparoscopic nephroureterectomy.

The effect of malarial infection on maternal-fetal outcome in Ecuador

OBJECTIVE

To describe maternal and fetal outcome among pregnancies complicated with malarial infection.

METHODS

Charts of pregnancies complicated with malarial infection were reviewed. Parasital etiology and maternal/fetal data was analyzed.

RESULTS

During the year 2001, at the Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil-Ecuador, 80 pregnancies complicated with malarial infection were admitted for treatment. This rendered an incidence of 2.1 per 1,000 live births (80/37,579). Mean maternal age was 25.2 +/- 6.7 years and the 19-29 age group was the most frequently affected (50%). On admittance, fever, chills, jaundice and anemia was present in 97.5%, 78.8%, 38.8% and 60% respectively. Falciparum was the most frequently presenting species (56.3%). Patients admitted at < 20 weeks gestation (n = 17) had a 76.5% and 82.4% abortion and adverse fetal outcome rate respectively. Among those admitted at 20-36 weeks (n = 55) the rates for preterm birth, intrauterine fetal death, low birthweight (LBW) and small-for-gestational age (SGA) were 34.5%, 11%, 40.8% and 48.9% respectively. Among patients admitted > 36 weeks, 87.5% (7/8) ended in a live term delivery. Adolescents presented a higher rate of anemia and SGA neonates. The overall (n = 80) abortion, preterm delivery and intrauterine fetal demise rates were 16.3%, 25% and 8.8% respectively. Chloroquine effectively treated 98.8% of cases and there was one maternal death due to falciparum infection.

CONCLUSIONS

In this Ecuadorian population, malarial infection complicating gestation was associated to adverse maternal-fetal outcome, which was more evident among teenagers and pregnancies presenting malaria at an earlier gestational age.

The early course of kidney allograft rejection: defining the time when rejection begins

We studied the early events in mouse kidney allografts and isografts to define when allorecognition begins and when alloimmune tissue injury begins. Allografts but not isografts showed T-cell infiltration in perivascular areas from day 1, but tubulitis and arteritis did not develop until day 7. Flow cytometry confirmed the early allospecific CD3(+)CD8(+) T-cell infiltrate. At day 1, both allografts and isografts showed extensive transcriptome changes, reflecting the response to surgery, but only allografts showed expression of interferon-gamma (IFN-gamma)-inducible transcripts and T-cell-associated transcripts. Although the number of CD68(+) myeloid cell numbers did not increase in day 1 isografts or allografts, mRNA expression for myeloid markers was increased in isografts and allografts, suggesting activation of resident cells of the macrophage-dendritic cell series (MMDCs) in response to injury, followed by increased CD68(+) cell numbers from day 2. By day 3, an interstitial T-cell and MMDC infiltrate was established in allografts, corresponding with the emergence of allospecific tissue injury, as reflected by decreased parenchymal transcripts. Thus, in renal allografts, allorecognition by T cells occurs in perivascular sites by day 1, but alloimmune parenchymal damage begins at day 3, coinciding with the emergence of the interstitial T-cell-MMDC infiltrate.

[Orthotopic renal transplant: our experience]

Orthotopic renal transplant (ORT) is useful in cases of severe atherosclerosis, heterotopic bilateral transplant, unsuitable pelvic vessels and in aortic thrombosis, but it is not available in all the institutions and it is only realized of exceptional form.

AIM

To review the indication, surgical technique and outcome of the ORT at our hospital.

MATERIAL AND METHODS

The studied included five cases between January 1990 and December 2005. We analyzed several variables: demographic characteristics, characteristics of the donor, ischemia times, evolution of renal function and morbi-mortality associated.

RESULTS

Left ORT was performed in three men and two women. Mean patient age was 52+/-5 years, all the patients received kidneys from cadaveric donors. Mean creatinine and urea one month postoperative were 2.2+/-0.72 mg/dl and 103+/-17.2 mg/dl and at 6 months postoperative were 1.8+/-0.59 mg/dl and 78+/-14 mg/dl respectively. Immediately all patients received prophylaxis with low molecular weight heparin but it was indicated antiaggregation to two patients when they left the hospital, anticoagulation to two patients and to one of them was decided to anticoagulation nor antiagregation for history of bled digestive. A patient died for bleeding episode at level of the renal graft six months after the transplant, she was in treatment with dicumarinics, they were indicated by venous deep thrombosis in right leg. The survival a year is 80 % of the graft and the patient. Only two patients returned to hospital later, one of them for presenting an episode of diverticulitis and the other one for renal obstructive failure that needed laying of catheter pig-tail. Four patients presented stenosis of renal native vassels detected in control magnetic nuclear resonance, not symptomatic. There are two patients who take more than three years transplanted with renal stable function (creatinina 1.3 mg/dl and 1.4 mg/dl respectively).

CONCLUSION

ORT is an excellent option in patients with co-morbidity increased for atherosclerosis and that cannot be placed in the iliac fossaes.

Knowledge and practice of family planning and HIV-prevention behaviour among just delivered adolescents in Ecuador: the problem of adolescent pregnancies

BACKGROUND

Adolescents constitute a high risk population for the spreading of sexually transmitted diseases, among them HIV/AIDS. Knowledge regarding reproductive issues among them is a key point in order to establish appropriate prevention programs.

OBJECTIVE

Obtain information regarding the knowledge and practice related to family planning and HIV-prevention behaviour among adolescents of low income.

METHODS

Adolescents aged 19 or less delivering at the Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil, Ecuador were surveyed in the immediate postpartum period with a structured questionnaire designed for the purpose.

RESULTS

During the study period, 357 pregnant adolescents were surveyed. Mean age was 17.2 +/- 1.4 years, 30.8% were aged 16 or less. Demographical and obstetrical history differences were found when comparing adolescents in relation to age and educational level. A high rate of mothers had unplanned pregnancies (63.3%) or did not know what family planning was (49.6%). Despite high knowledge of what a condom or an oral contraceptive was, few had used them in the past. The most frequently known family planning methods in this series, which was age dependent, were: oral contraceptives (90.2%), condoms (84.9%), parenteral (66.7%) and intrauterine devices (63.3%). The majority knew what HIV/AIDS infection was, the most important sources of knowledge being: television, high school source, and family or relatives. A high rate of adolescents had never had an HIV test performed in the past with one prior tested adolescent resulting in a positive result. There was a high rate of knowledge regarding the most frequent HIV transmission routes: sexual intercourse, contact with infected blood and vertical transmission. In this series, although condom use was the most known way for HIV protection, only 22.2% answered having intercourse protected with this method.

CONCLUSION

In this adolescent series, older age was related to higher knowledge in family planning methods; in global despite finding a relatively high knowledge in family planning and HIV related issues, contraception use and HIV protection behaviour was low.

Menopausal symptoms and associated risk factors among postmenopausal women screened for the metabolic syndrome

BACKGROUND

Although the frequency of menopausal symptoms may vary according to the studied population, in general severe intensity has been related to lower quality of life.

OBJECTIVE

To assess the frequency of menopausal symptoms and involved risk factors in an Ecuadorian postmenopausal population.

METHODS

Postmenopausal women that participated in a metabolic syndrome screening program were interviewed with the Menopause-specific quality of life questionnaire (MENQOL) in order to determine the most frequently presenting menopausal symptoms and correlate these symptoms with socio-demographic data and the main results of the screening program.

RESULTS

Three hundred and twenty-five postmenopausal women (n = 325) were surveyed with the MENQOL. Mean age of participants was 55.9 +/- 8.1 years (median: 54 years). The most frequently presenting symptoms were: hot flushes (53.3%), sweating (49.2%), poor memory (80.6%), feeling depressed (67.4%), aching in muscles and joints (84%), drying of their skin (85.5%), avoiding intimacy (76.2%) and change in their sexual desire (76.5%). Multivariate analysis determined that abdominal obesity was a significant risk factor for presenting hot flushes, depression and muscle and joint pain. High triglyceride levels were associated to higher rates of sweating and depression. While women with basal hyperglycemia were associated to dry skin and changes in sexual desire in a higher proportion, those who were older and with more years of menopause onset were related less frequently to vasomotor symptoms. Older age was also significantly associated in a higher rate to dry skin.

CONCLUSION

In this postmenopausal Ecuadorian population, the frequency of menopausal symptoms, as assessed with the MENQOL, was found to be relatively similar to other Latin and non-Latin American populations and associated to age, hormonal status and related metabolic conditions.

The influence of hepatitis C virus-human immunodeficiency virus co-infection on the appearance of liver enzyme elevation in people on high activity antiretroviral treatment

BACKGROUND

Liver enzyme elevation (LEE) as a consequence of HAART is a problem among patients with HIV-HCV co-infection.

METHODS

In this retrospective study, 145 patients with HIV who were on HAART and who developed LEE grades 3 and 4 of the World Health Organization (WHO) were followed up. Basal ALT, alcohol consumption, and HCV and HBV co-infection were recorded. Comparisons were made between patients with and without HCV co-infection.

RESULTS

Three patients without co-infection presented LEE grade 3 versus 38 with co-infection (104 episodes). An increase in basal ALT (RR: 1.01) and HCV co-infection (RR: 6.6) were the variables associated with LEE grade 3. The number of days that HAART had to be withdrawn due to LEE was 58.15 and 4.85 in subjects with and without co-infection, respectively (p=0.024).

CONCLUSION

Patients with HCV-HIV co-infection have more episodes of LEE and must go longer without HAART than people without co-infection.

International conference on the healthy effect of virgin olive oil

1. Ageing represents a great concern in developed countries because the number of people involved and the pathologies related with it, like atherosclerosis, morbus Parkinson, Alzheimer's disease, vascular dementia, cognitive decline, diabetes and cancer. 2. Epidemiological studies suggest that a Mediterranean diet (which is rich in virgin olive oil) decreases the risk of cardiovascular disease. 3. The Mediterranean diet, rich in virgin olive oil, improves the major risk factors for cardiovascular disease, such as the lipoprotein profile, blood pressure, glucose metabolism and antithrombotic profile. Endothelial function, inflammation and oxidative stress are also positively modulated. Some of these effects are attributed to minor components of virgin olive oil. Therefore, the definition of the Mediterranean diet should include virgin olive oil. 4. Different observational studies conducted in humans have shown that the intake of monounsaturated fat may be protective against age-related cognitive decline and Alzheimer's disease. 5. Microconstituents from virgin olive oil are bioavailable in humans and have shown antioxidant properties and capacity to improve endothelial function. Furthermore they are also able to modify the haemostasis, showing antithrombotic properties. 6. In countries where the populations fulfilled a typical Mediterranean diet, such as Spain, Greece and Italy, where virgin olive oil is the principal source of fat, cancer incidence rates are lower than in northern European countries. 7. The protective effect of virgin olive oil can be most important in the first decades of life, which suggests that the dietetic benefit of virgin olive oil intake should be initiated before puberty, and maintained through life. 8. The more recent studies consistently support that the Mediterranean diet, based in virgin olive oil, is compatible with a healthier ageing and increased longevity. However, despite the significant advances of the recent years, the final proof about the specific mechanisms and contributing role of the different components of virgin olive oil to its beneficial effects requires further investigations.

Factors associated with inadequate prenatal care in Ecuadorian women

BACKGROUND

Although inadequate prenatal care has been associated with adverse perinatal outcomes, reports on the factors associated with poor prenatal care in developing Latin American countries are scarce.

OBJECTIVE

To determine factors associated with inadequate prenatal care among women from low socioeconomic circumstances.

METHOD

Women delivered after a pregnancy duration of more than 20 weeks at the Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil, Ecuador, were surveyed. The questionnaire collected sociodemographic data and reasons for having inadequate prenatal care. Adequacy of prenatal care was measured with the Kessner index and correlated to the sociodemographic data.

RESULTS

During the study period, 1016 pregnant women were surveyed. Among them, there were adolescents (23.7%), primigravidas (30.8%), and women with a high-risk pregnancy (29.3%). According to the Kessner index, prenatal care was considered adequate or inadequate in 24.5% and 75.5% of cases, respectively. Knowledge regarding the importance of adequate prenatal care and the effects of poor prenatal care was lower among women who had received inadequate prenatal care. The women that were considered to have had adequate prenatal care had at least one visit, and they were more often cared for by a specialist than women who considered having inadequate prenatal care. The three most important reasons associated to inadequate prenatal care in this series (n=767), were economic difficulties having to care for a small child, and transportation difficulties. Logistic regression analysis determined that women with undesired pregnancies who resided in rural areas and were para 5 or higher had an increased risk of inadequate prenatal care. On the other hand, an adverse outcome to a prior pregnancy (abortion, intrauterine fetal demise, or ectopic pregnancy) decreased this risk. Marital status and educational level were confounding factors.

CONCLUSIONS

Although prenatal care at our institution is free, adequacy was thought to be low. The main factors associated with poor prenatal care were mostly conditions related to poverty.

Effect of cholecystokinin-A receptor blockade on postprandial insulinaemia and gastric emptying in humans

Our aim was determine the relationship between cholecystokinin (CCK)-A receptor blockade, glucose levels, insulin secretion and gastric emptying in humans, and to assess the effect of CCK-A blockade on pancreatic polypeptide secretion. After a 12-h fast, six healthy volunteers were given [99mTc]iminodiacetic acid monosodium salt (IDA) intravenously (5 mCi). One hour later they were offered a 577 kcal liquid meal containing [99mTc]diethylenetriaminepentaacetic acid (DTPA) (2 mCi) and glucose (105 g). Scintigraphic gastric and gallbladder activity, and plasma glucose, insulin and pancreatic polypeptide responses were monitored. In a second experiment, a continuous intravenous infusion of loxiglumide (7.5 mg kg h(-1)) was started 60 min before and continued until 120 min after test meal ingestion to block the CCK-A receptors. Gallbladder emptying was blocked by loxiglumide. Loxiglumide accelerated gastric emptying, increased insulin secretion without alteration of glucose profiles, and abolished all phases of the postprandial pancreatic polypeptide response. Blockade of peripheral CCK-A receptors accelerates gastric emptying of liquids with an increase in postprandial insulin levels. The lack of changes in glycaemia suggests that alternative homeostatic mechanisms also control postprandial glucose levels. Inhibition of pancreatic polypeptide release may reflect an independent effect of loxiglumide on vagal control involved in pancreatic polypeptide release.

[First two years of an external quality assurance program for urinalysis]

OBJECTIVE

To analyze the first two years of a strip uroanalysis quality assurance scheme operating in Mexico.

METHODS

The participants received 8 shipments of four controls each as dried tablets to be dissolved and analyzed with urine strips. The number of participants increased from < 50 in the 1st shipment to > 200 in the 8th. They assayed 6-10 analytes depending on the strip used and sent in 763 reports. For each report we calculated a score per analyte (n = 4), per shipment (n = 24 to 40) and a global score in the 8 shipments (n = 707 to 763 reports). The scores ranged from zero (excellent accuracy) to a maximum of 400 and were calculated by comparison with the modal value of about 600 American and Canadian laboratories which assayed the same controls using exclusively Bayer strips and instrumental readings.

RESULTS

The best score was for nitrites (global score of 3 in 741 reports) and the worst for specific gravity (58 in 744 reports); the other analytes had scores from 11 to 19 (Table 1). The scores of four types of methods (Table 2) showed the best results with Bayer strips and instrumental readings (score of 13 in 469 reports) and the worst with strips of other suppliers (scores of 28 for visual and 31 for instrumental readings) and intermediate with visual readings of Bayer strips (score of 21).

CONCLUSIONS

1. Our results led us to the decision to exclude from the program participants who do not use Bayer strips as our program may disorient them instead of helping to improve their assays. 2. We confirmed that instrumental readings perform better than visual readings. 3. The causes of suboptimal performance in specific gravity need to be explored.

[Molecular changes in adenocarcinoma of the small intestine associated with Peutz-Jeghers syndrome]

The presence of molecular alterations in the c-K-ras and p53 genes in a small bowel adenocarcinoma arising in a case of Peutz-Jeghers syndrome is reported. The absence of mutations at codon 12 and 13 of the c-K-ras gene in the hamartoma and carcinoma indicates that this oncogene does not contribute to its development. On the other hand, p53 protein overexpression was detected in a small proportion (5-10%) of adenocarcinoma cells. Our findings suggest that p53 inactivation occur in late stages of tumour progression.

Lovastatin versus bezafibrate for hyperlipemia treatment after heart transplantation

BACKGROUND

Elevation in total and low-density lipoprotein cholesterol levels and a decrease in high-density lipoprotein cholesterol plasma concentrations are common in heart transplant recipients. The pathogenesis of this hyperlipemia after heart transplantation is complex. Currently available antilipemic agents are difficult to use because their adverse effects are potentiated by immunosuppressor treatment. The present investigation was carried out to test the safety and efficacy of lovastatin and bezafibrate in 18 patients with hyperlipemia after heart transplantation.

METHODS

In this crossover study, after 3 months of dietary recommendations, the subjects were randomly assigned to an 8-week period of lovastatin treatment (10 mg/day) followed by an additional 8-week period of treatment with bezafibrate (400 mg/day) or vice versa. The two treatments were separated by an 8-week washout period.

RESULTS

Both drugs reduced total and low-density lipoprotein cholesterol and apoprotein B concentrations. High-density lipoprotein cholesterol was only increased with bezafibrate. The total cholesterol/high-density lipoprotein cholesterol and low-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratios were decreased under both treatments, but these changes were greater with bezafibrate. Apo AI levels increased with lovastatin. Bezafibrate produced a rise in high-density lipoprotein cholesterol and reduced total and very low-density lipoprotein triglycerides and very low-density lipoprotein cholesterol. Both drugs decreased intermediate density lipoprotein cholesterol and triglyceride levels, but the effect of bezafibrate on intermediate-density lipoprotein triglycerides was significantly greater. The two drugs were well tolerated and liver enzymes, creatine kinase, and renal function remained stable.

Comparison of lovastatin and bezafibrate on lipoprotein(a) plasma levels in cardiac transplant recipients

Our results suggest that bezafibrate may be useful in the treatment of high Lp(a) levels in heart transplant patients.

[Changes in the cellular proliferation of the healthy mucosa in patients with colorectal cancer]

AIM

To analyze differences in the proliferative pattern of normal mucosa between patients with colorectal cancer and healthy subjects.

PATIENTS AND METHODS

By using flow cytometry we examined the proliferative pattern (Proliferative Index and S-Phase) in samples of normal mucosa from 34 patients operated on for colorectal cancer at our hospital and from 14 healthy subjects as a control group.

RESULTS

All examined samples were diploid. The Proliferative Index and S-Phase in the Cancer Group were significantly higher than in the Control Group (16.7 +/- 5.9 vs 11.4 +/- 4, p < 0.003, and 11.9 +/- 3.9 us 6.6 +/- 3 p < 0.0004).

CONCLUSIONS

These findings provide evidence for an altered proliferative pattern in the healthy colonic mucosa of patients with colorectal cancer.

[Primary bladder adenocarcinoma: retrospective study of 11 cases and general review]

Eleven cases of primary adenocarcinoma of the bladder are described herein. Eight had a glandular pattern, 1 was papillary and 2 were comprised of signet ring cells (one had areas of colloid carcinoma). One of the cases, originating from the urachus, also showed colloid areas and a glandular pattern. Forty-five percent of the cases were moderately differentiated and the remaining 55% were poorly differentiated. In all cases the tumor had areas of adenocarcinoma in more than 2/3 of its extent. All but two cases revealed muscle layer infiltration at the time of diagnosis. Two patients were submitted to radical cystectomy, lymphadenectomy and Wallace II cutaneous ureteroileostomy, 1 patient underwent partial cystectomy and lymphadenectomy, and 6 were submitted to transurethral resection. Excision of the urachal tumor was by en bloc partial cystectomy. The 5-year survival of patients with infiltrating tumors, excluding the urachal tumor, was 33%, 67% died within the first year of follow-up. The only evaluable case of superficial adenocarcinoma is alive and tumor-free at 94 months. Primary adenocarcinoma of the bladder is an aggressive tumor. Although it may be superficial at the time of diagnosis, it soon develops into an infiltrating tumor if untreated. Treatment and survival depend on tumor stage. Superficial or minimally infiltrating tumors warrant treatment by deep transurethral resection up to the pericystium.(ABSTRACT TRUNCATED AT 250 WORDS)

Post-transplant renal artery stenosis: a possible immunological phenomenon

A retrospective review of 110 consecutive kidney transplants performed during 4 years revealed the development of renal artery stenosis in 9 patients (8.18%). A comparison of this group with a control group similar in patient age and interval elapsed since transplantation revealed no significant differences in donor and recipient ages, degree of HLA compatibility or serum creatinine levels. However, there was a significant difference in the number of acute rejection episodes. In our series only male patients were affected. A sizable proportion of the patients (50%) had no detectable murmur over the graft area despite high blood pressure and increased creatinine levels. The absence of surgical injury during extraction and implantation of the grafts, together with the anatomical site of the stenosis and correlation with the degree of immunological intolerance suggest an immunological factor as the underlying cause in post-transplant renal artery stenosis.

[The indications for benzodiazepines in the treatment of insomnia]

We interviewed 219 patients with a questionnaire to evaluate the prevalence of insomnia, and to assess whether benzodiazepine therapy was correctly indicated. Insomnia was present in 86 patients (39%), being initial in more than one half. Thirty-two of the patients with insomnia were receiving benzodiazepines (37%), 24 of whom (75%) had been treated for more than one year. The drug was incorrectly indicated in 18 (56%), in most cases because it was inappropriate for the type of the patient's insomnia. In six of these patients (33%), incorrect indication was related with self-medication. The benzodiazepine was incorrectly indicated in all the patients with diurnal oversedation. We emphasize the frequency of incorrect indications of these drugs, and we insist on the need that general practitioners have of a better knowledge of the pharmacokinetics of each drug, which is the basis for a correct indication.

[Value of parenteral nutrition in total gastrectomy for cancer. A prospective study]

A prospective study is presented in which the impact of total parenteral nutrition (TNP) was analyzed in a group of 27 patients that underwent total gastrectomy due to gastric carcinoma (TGGC). Patients were randomly divided into two groups: Group I was formed by 15 patients and was treated systematically with TPN during the immediate postoperative period (POTPN). Group II was formed by 12 patients who were treated with conventional serum therapy during the immediate postoperative period. TPN was administered if enteral nutrition was not viable and/or patients presented complications. Both groups were similar regarding age, sex, previous illness, previous nutritional status (Preop PNI) and surgical technique used in GI transit reconstruction. Morbidity and mortality rates, nutritional status (PNI 5 days postop) and mean hospital stay were analyzed in both groups. Likewise, a retrospective comparison was made between the results obtained from this trial and those from a group of 44 patients with gastric carcinoma who underwent TGGC at our hospital a decade earlier and did not received TPN during the immediate postoperative period on a routine basis. When both series and Groups I and II were compared significant differences in mean hospital stay were observed in favor of Group I treated with routine TPN in the immediate postoperative period. There were no differences in the mortality rate when all groups were compared. It was concluded that TPN was useful in patients undergoing TGGC because it reduced postoperative mortality rate, decreased mean hospital stay and showed good cost/effectiveness correlation.

[Is it necessary to combine the surgical treatment of kidney adenocarcinoma with ipsilateral adrenalectomy?]

We analyzed a series of 202 renal adenocarcinomas, 164 of which were submitted to radical nephrectomy. Pathological analyses of 150 adrenal glands revealed ipsilateral adrenal metastasis in 4 cases, 3 of these coexisting with other distant metastases. The primary tumors in these 4 cases were highly undifferentiated and in the advanced local tumor stage; the only case with solitary adrenal metastasis survived 15 months. The present study and data reported in the literature indicate that ipsilateral adrenalectomy should be performed in addition to radical nephrectomy only in renal tumors of the upper pole, those localized at other sites but whose size indicate the possibility of tumor spreading to the adjacent adrenal gland, or when a suspicious mass in the adrenal gland is evidenced by the preliminary workup or during surgery.

[Kaposi's sarcoma in kidney transplant treated with cyclosporin and azathioprine]

We report on a renal transplant patient who had developed Kaposi's sarcoma with cutaneous involvement 20 days after transplantation. The patient had a functioning renal graft and was on immunosuppressive therapy consisting of prednisone, azathioprine and cyclosporine. Azathioprine and cyclosporine were discontinued and chemotherapy was instituted with vinblastine first and methotrexate later; however, Kaposi's tumor did not respond to the foregoing therapeutic regimen. Thirty-two months following transplantation, the kidney graft presented acute interstitial rejection that warranted graft removal. The patient is currently receiving treatment for Kaposi's sarcoma but tumor regression has not been achieved. We discuss the atypical course of this case in comparison with those reported elsewhere.

[Management of injury of the solitary kidney]

Two cases of renal trauma are described herein. The diagnostic work up revealed the patients had solitary kidney. Trauma was classified as grade 1 and 2 and a conservative approach was adopted. The patient with grade 2 trauma was submitted to surgery one month following treatment. Preservation of the renal unit was achieved in both patients. Patient follow up at 16 years revealed no complications or sequelae from the injury. The diagnostic and therapeutic aspects of renal trauma in patients with solitary kidney are discussed.

[Oat cell carcinoma of the esophagus]

Extrapulmonary locations of undifferentiated small cell carcinoma of the "oat cell" type are uncommon. In spite of its rarity, the appearance of this type of tumor has been described in various organs of the economy. Of these, the esophagus is the most common location, constituting 0.05 to 7.6% of esophageal carcinomas. Of uncertain histopathologic origin, these tumors are characterized by their extreme aggressiveness, which carries a poor short term prognosis. Surgery, radiotherapy and chemotherapy, separately or in combination, have produced discouraging results in the treatment of primitive esophageal "oat cell" carcinoma. In this paper are presented four cases of esophageal "oat cell" carcinoma treated in the Hospital de la Santa Cruz y San Pablo in 1979-1988, out of a total of 260 carcinomas in the same location. The clinical evolution and pathological findings of this type of tumor are commented. The literature on this unusual histological type of carcinoma is reviewed.