Global evidence, impact and implementation of U=U

This Special Issue brings together the most recent body of evidence supporting the concept of Undetectable equals Untransmittable (U=U). The included manuscripts explore the scientific foundations and origins of U=U, highlight the advantages of U=U, examine its implementation in specific groups of people, advocate for U=U, and present case studies from different countries.

What is the relevance of seminal plasma from a functional and preservation perspective?

When preserving sperm in the liquid or cryopreserved state, seminal plasma (SP) components within ejaculates can alter fertilizing capacity of these gametes. Depending on the species or how semen is collected, volume and concentration of SP components varies considerably. The SP contains substances essential for maintenance of sperm viability and fertility; however, these components can be deleterious depending on quantity, or duration of time before there is removal of SP from sperm in semen processing. Substances that impair (e.g., BSP - bull; HSP-1 - stallion; Major seminal plasma protein PSPI - boar) or improve (e.g., spermadhesin PSP-I - boar) spermatozoa fertilizing capacity have been identified. Depending on individual males, species, and semen collection procedures, SP removal may be beneficial before preservation in the liquid or cryopreserved state. In some cases, SP that is removed can be added back to thawing extender with there being positive effects in thawed sperm and for sperm viability in the female reproductive tract. In this review article, there is a focus on different effects of SP in samples of cooled and cryopreserved semen from four domestic species (pigs, horses, cattle, and sheep) with there being emphasis on how SP modulates the function and morphology of sperm cells before, during, and after preservation in the refrigerated or cryopreserved state. The present review is part of the Festschrift in honor of Dr. Duane Garner who made major contributions to the area of focus in this manuscript as evidenced by the many times his research is cited in this manuscript.

P6422Physician vs machine: an innovative ST-elevation myocardial infarction pathway through artificial intelligence

Background

The diagnosis of ST-Elevation Myocardial Infarction (STEMI) has traditionally relied on a cardiologist's interpretation of an Electrocardiogram (EKG). This cumbersome process is costly, inefficient and out of date. Artificial Intelligence (AI) -guided algorithms can provide point-of-care, accurate STEMI diagnosis that will facilitate STEMI management.

Purpose

To demonstrate the feasibility of an automated AI-guided EKG analysis for STEMI diagnosis.

Methods

An observational, retrospective, case-control study. Sample: 8,511 EKG cardiologist-annotated records, including 4,255 STEMI cases. Records excluded patient and medical information. The sample was derived from the private International Telemedical Systems (ITMS) database. LUMENGT-AI Algorithm was employed. Preprocessing: detection of QRS complexes by wavelet system, segmentation of each EKG into individual heartbeats (90,592 total beats) with fixed window of 0.4s to the left and 0.9s to the right of main QRS; Classification: A 1-D convolutional neural network was implemented, “STEMI” and “Not-STEMI” classes were considered for each heartbeat, individual probabilities were aggregated to generate the final label for each record. Training & Testing: 90% and 10% of the sample were used, respectively. Experiments: Intel PC i7 8750H processor at 2.21GHz, 16GB RAM, Windows 10 OS with NVidia GTX 1070 GPU, 8GB RAM.

Results

The model achieved an accuracy of 96.5%, with a sensitivity of 96.3%, and a specificity of 96.8%.

Conclusion(s)

1) AI-guided interpretation of the EKG can reliably diagnose STEMI; 2) AI algorithms can be incorporated into ambulance systems for pre-hospital diagnosis, single page activation, emergency department bypass, facilitating more efficient STEMI pathways.

P1464Adoption of feedback to validate a machine learning model for single lead STEMI detection

Background

We have explored the performance of a single lead EKG with Artificial Intelligence (AI) based algorithms in STEMI diagnosis, thus far lead V2 has yielded the best results. Anticipating the performance of the LUMENGT-AI model, we designed a feedback strategy with healthcare centers to expand the validation of our work.

Purpose

To create a pragmatic alternative to the existing gold standard, a 12-lead EKG, for STEMI diagnosis.

Methods

An observational, retrospective, case-control study. Sample: 2,543 exclusively STEMI (anterior, inferior and lateral wall) diagnosis, EKG records. Feedback: From healthcare centers, confirming STEMI diagnosis and location, was obtained (thrombolysis, primary Percutaneous Coronary Intervention (PCI), pharmaco invasive therapy or coronary artery bypass surgery). Records excluded other patient and medical information. Sample was derived from the private International Telemedical Systems (ITMS) database. LUMENGT-AI Algorithm was employed. Preprocessing: detection of QRS complexes using the wavelet system, segmentation of each EKG into individual heartbeats (53,667 total beats) with fixed window of 0.4s to the left and 0.9s to the right of main QRS; Classification: A 1-D convolutional neural network was implemented; “STEMI” and “Not-STEMI” classes were considered for each heartbeat per lead; individual probabilities were aggregated to generate the final label for each record. Training & Testing: 90% and 10% of the sample were used, respectively. Experiments: Intel PC i7 8750H processor at 2.21GHz, 16GB RAM, Windows 10 OS with NVidia GTX 1070 GPU, 8GB RAM.

Results

V2 was the most precise lead with an Accuracy of 93.6%, a Sensitivity of 89%, and a Specificity of 94.7%.

Conclusions

The strategic adoption of feedback from healthcare centers provided strong validation of our model. The results of AI-augmented, single lead EKG are encouraging. We anticipate that this approach will become a promising methodology in STEMI detection.

P1524Women are from venus and face barriers for AMI treatment

Background

The Latin American Telemedicine Infarct Network (LATIN), a program for managing population-based AMI care, has utilized an innovative hub-spoke strategy and remote guidance to expand medical access in remote parts of Brazil, Colombia, Mexico, and Argentina. Based on the Global Lumen Organization for Women (GLOW) project, that has previously demonstrated gender inequalities and worse outcomes for women who undergo Primary PCI, our research explored the management of female patients in our network.

Purpose

To demonstrate gender disparities in a telemedicine-guided, population based AMI program.

Methods

Meta-analysis of >750,000 patients within LATIN. Telemedicine was employed as a screening tool to accurately diagnose AMI. According to the duration of chest pain and transfer time, AMI patients were triaged into guidelines-based pathways of thrombolysis, pharmaco-invasive management or Primary PCI. Resource allocation was identical for men and women.

Results

Data from 784,395 screened patients reveals broad gender disparities. The critical results yielded that female patients have a lower prevalence of STEMI diagnosis and treatment regardless of the technique – PCI, pharmaco-invasive or CABG (p<0.01). These findings assume more significance given the fact that more women than men, were screened through the Telemedicine pathway.

Conclusions

LATIN gender data signals the urgency to demand better AMI care for women.

P6421Can cardiologists rely on artificial intelligence to identify the culprit vessel in STEMI?

Background

The importance of culprit lesion identification is critical for risk stratification of a patient with an ST-Elevation Myocardial Infarction (STEMI). The aforementioned provide patients with a more elaborated strategy of management and treatment either they are treated with PCI or less invasive techniques such as thrombolysis. We report a novel approach that employs AI-guided electrocardiogram (EKG) algorithms for rapid and accurate identification of the culprit STEMI vessel.

Purpose

To create an innovative, machine learning tool for a more effective risk stratification of STEMI patients.

Methods

An observational, retrospective, case-control study. Sample: 2,542 exclusively STEMI diagnosis EKG records that included post discharge feedback from healthcare centers, confirming diagnosis and culprit vessel (Left Main Coronary Artery [LMCA]; Left Anterior Descending [LAD]; Right Coronary Artery [RCA]; Left Circumflex Artery [LCX]; Saphenous Vein Graft [SVG]). Records excluded other patient and medical information. The sample was derived from the private International Telemedical Systems (ITMS) database. LUMENGT-AI Algorithm was employed. Preprocessing: detection of QRS complexes using a wavelet system, segmentation of each EKG into individual heartbeats (27,125 total beats) with fixed window of 0.4s to the left and 0.9s to the right of main QRS; Classification: A 1-D convolutional neural network was implemented; “LCMA”, “LAD”, “LCX”, “RCA”, “SVG”, and “No Information” classes were considered for each heartbeat; individual probabilities were aggregated to generate the final label for each record. Training & Testing: 90% and 10% of the sample was used, respectively. Experiments: Intel PC i7 8750H processor at 2.21GHz, 16GB RAM, Windows 10 OS with NVidia GTX 1070 GPU, 8GB RAM.

Results

Global Accuracy: 79.4%; LAD: Sensitivity 86.2%; Specificity 84.8%. RCA: Sensitivity 85.7%; Specificity 83.7%. LCX: Sensitivity 43.5%; Specificity 96.9%.

Conclusions

Coupling an AI-augmented algorithm and 12-lead EKG provides encouraging results for STEMI culprit vessel localization. Overall, risk stratification is possible for individual lesions located in the LAD and RCA. However, our approach yielded uncertain results in the LCX territory. We plan to continue to exploring variables for improvement of our results.

P1928Global telemedicine initiatives for combating ami

Background

Major disparities exist between developed and developing countries in Acute Myocardial Infarction (AMI) outcomes. Telemedicine has emerged as a powerful, cost-efficient, and scalable tool for population-based AMI management. We propose efficient telemedicine protocols as frontline AMI strategies for resource-constrained developing countries.

Purpose

To create a global template of using telemedicine protocols for treating AMI.

Methods

A hub and spoke strategy was utilized for Latin America Telemedicine Infarct Network (LATIN) to expand access in Brazil, Colombia, Mexico, and Argentina. Small clinics and primary care health centers in remote areas were strategically connected with 24/7 primary PCI facilities. Experts at 4 remote sites provided urgent EKG diagnosis and tele-consultation that triggered ambulance dispatch and implementation of standardized AMI protocols.

Results

784,947 patients were screened for AMI at 350 LATIN centers (Brazil 143, Colombia 118, Mexico 82, Argentina 7). With this expanded geographic reach, 8,448 (1.08%) patients were diagnosed with STEMI and 3,911 (46.3%) urgently reperfused, including 3,049 (78%) with Primary PCI. Time to Telemedicine Diagnosis (TTD) was 3 min, tele-accuracy 98.9%, D2B 51 min, and in-hospital mortality 5.2%. Major reasons for non-treatment were insurance denials, lack of ICU beds and chest pain >12 hours.

Conclusions

LATIN demonstrates the feasibility of a population-based and telemedicine guided AMI strategy that can hugely expand access. Telemedicine has important public health implications as a global approach to AMI care in developing countries.

P1742Is time to telemedicine diagnosis (TTD) analogous to door to balloon time?

Background

Telemedicine is a powerful, cost-efficient, and scalable tool for population-based AMI management. Traditional metrics of D2N, D2B do not gauge telemedicine effectiveness. We explored the utility of TTD in 784,947-screened patients within the Latin America Telemedicine Infarct Network (LATIN).

Purpose

To evaluate the competence of TTD as an efficiency indicator in telemedicine.

Methods

LATIN employed a spoke-hub strategy to expand access in Brazil, Colombia, Mexico, and Argentina. Small clinics (spokes) in remote areas were strategically connected to PCI-capable facilities (hubs). Experts at 4 remote locations provided urgent EKG diagnosis via tele-consultation, additionally, they triggered ambulance dispatch and implementation of guidelines-based protocols. Investing in updated telemedicine technology provided a system-wide TTD reduction.

Results

714,450 patients were screened for AMI at 350 LATIN centers (Brazil 143, Colombia 118, Mexico 82, Argentina 7). Within our territories 8,448 (1.08%) patients were diagnosed as STEMI; 3,911 (46.3%) were urgently reperfused, of those 3,049 (78%) underwent Primary PCI. TTD was 3 min, demonstrating 98.9% tele-accuracy. D2B was 51 min; in-hospital mortality 5.2%. We encountered a linear correlation between D2B and TTD. The latter was, also, inversely related to the number of screened patients - both associations are favorable for LATIN.

Conclusions

TTD is an important indicator of telemedicine efficiency. LATIN will continue to explore this value's strength and other important associations.

P1466Can physicians trust a machine learning algorithm to diagnose ST elevation myocardial infarction?

Background

For the past years, the medical field has been taking advantage of the endless possibilities that Artificial Intelligence (AI) provides. Using computer-aided devices that can perform and interpret electrocardiograms (EKG) accurately pushes current healthcare boundaries. We present the LUMENGT-AI, this model can handle large datasets, multiclass diagnoses, complex EKG morphology, and still detect ST Elevation MI (STEMI) accurately.

Purpose

To develop an innovative AI-based system for automated STEMI specific EKG analysis.

Methods

An observational, retrospective, case-control study. Sample: 8,511 EKG records, previously diagnosed as “normal”, “abnormal” (over 200 conditions) or “STEMI” (4,255 cases). Records excluded patient and medical information. The sample was derived from the private International Telemedical Systems (ITMS) database. LUMENGT-AI Algorithm was employed. Preprocessing: detection of QRS complexes by wavelet system, segmentation of each EKG into individual heartbeats (90,592 total beats) with fixed window of 0.4s to the left and 0.9s to the right of main QRS; Classification: A 1-D convolutional neural network was implemented, “STEMI” and “Not-STEMI” classes were considered for each heartbeat, individual probabilities were aggregated to generate the final label for each record. Training & Testing: 90% and 10% of the sample were used, respectively. Experiments: Intel PC i7 8750H processor at 2.21GHz, 16GB RAM, Windows 10 OS with NVidia GTX 1070 GPU, 8GB RAM.

Results

Ground Truth Score – Accuracy (94.1%), Sensitivity (87.8%), Specificity (98.1%) – see the comparison to published data in Table.

Conclusions

A statistical analysis allowed us to compare STEMI recognition efficiency between physicians and our model. The LUMENGT algorithm results secured its place as a reliable tool to diagnose STEMI faster and more accurately than physicians.

P1751LATIN - A template for effective AMI management in developing countries

Background

In resource-constrained nations, population-based AMI coverage is daunting. Telemedicine can transform the situation through an efficient, cost-effective and scalable program called the Latin America Telemedicine Infarct Network (LATIN). We present our innovative hub-spoke strategy, that has served >780,000 patients.

Purpose

To use telemedicine protocols to demonstrate appropriate access to quality AMI care, encompassing remote areas.

Methods

LATIN required technology and process metrics optimization as well as a scrupulous site selection, during a 12-month pilot. Spokes represent our strategy's nucleus; they consist of small, rural clinics and resource-limited facilities that are connected to PCI-capable hubs. Spokes require constant (3-T) training: Triage, Telemedicine, and Transportation. The latter two categories are the most challenging because they demand constant upgrading.

Results

784,395 patients were screened at 350 LATIN centers (Brazil 143, Colombia 118, Mexico 82, Argentina 7). A total of 8,440 (1.08%) patients were diagnosed with AMI; 3,924 (46.5%) were urgently reperfused including 3,048 (77.7%) who underwent PCI. Globally, Time to Telemedicine Diagnosis (TTD) was 3 min exhibiting 98.9% tele-accuracy, D2B was 51 min, additionally, in-hospital mortality was 5.2%. Major reasons for non-treatment of patients were insurance, lack of ICU beds and delayed presentation.

Conclusions

LATIN is a valuable healthcare system prototype for developing countries. Our hub-spoke strategy focuses on providing adequate AMI management for populations. However, aspects such as ambulance availability, insurance denial and lack of ICU beds must be targeted to improve performance.

P6417Increasing the accuracy of a machine learning algorithm for STEMI diagnosis by incorporating demographic variables

Background

Our previous work demonstrated the diagnostic value of Artificial Intelligence (AI) -driven algorithms for ST-Elevation Myocardial Infarction (STEMI). In the present research, we explore the importance of demographic data inclusion, in order to achieve a more accurate diagnosis.

Purpose

To demonstrate that incorporation of demographic variables into the sample records will augment the accuracy of AI-based protocols for STEMI diagnosis.

Methods

An observational, retrospective, case-control study. Demographic data (age and gender) male/female ratio 1.3, ages 98–18 years was added to the sample records. Sample: 8,511 EKG records, previously diagnosed as normal, abnormal (over 200 conditions) or STEMI. Records excluded other patient and medical information. The sample was derived from the private International Telemedical Systems (ITMS) database. LUMENGT-AI Algorithm was employed. Preprocessing: detection of QRS complexes by wavelet system, segmentation of each EKG into individual heartbeats (90,592 total beats) with fixed window of 0.4s to the left and 0.9s to the right of main QRS; Classification: A 1-D convolutional neural network was implemented, “STEMI” and “Not-STEMI” classes were considered for each heartbeat, individual probabilities were aggregated to generate the final label for each record. Training & Testing: 90% and 10% of the sample was used, respectively. Experiments: Intel PC i7 8750H processor at 2.21GHz, 16GB RAM, Windows 10 OS with Nvidia GTX 1070GPU, 8GB RAM.

Results

The model yielded an accuracy of 97.1%, a sensitivity of 96.8%, and a specificity of 97.5%.

Conclusions

The ability of AI-guided algorithms to diagnose STEMI is increased by expanding the morphological variables with demographic data. This approach may be applied to improve the EKG diagnosis of other cardiovascular entities and improve clinical management.

P6142LATIN telemedicine - expanded umbrella of cost-effective ami coverage for 100 million people

Background

AMI is a unique entity where the immediate diagnosis can be made by a single test, the EKG. Despite this matchless attribute of easy diagnosis, developing (and some developed) countries lack resources and efficient pathways for urgent and reliable diagnosis of AMI. With Latin Telemedicine Infarct Network (LATIN), we have previously presented Telemedicine as a pragmatic solution for urgent and accurate diagnosis of AMI. In this work, we reveal pathways of scalable population-based AMI management models.

Purpose

To utilize telemedicine as a foundation pillar for creating cost-effective and global models of AMI management.

Methods

LATIN pilot tested the hypothesis of remote guidance of AMI management and expanded access by creating a hub and spoke, STEMI systems of care that exploited regional resources. A highly efficient, web-based, cloud-computing prototype was developed and scrupulously monitored with a new metric of time to telemedicine diagnosis (TTD). STEMI systems of care were created to efficiently triage the diagnosed patients for being treated with thrombolysis, pharmaco-invasive management or Primary PCI. This stratagem had enormous provincial variability and was constrained mainly by ambulance structure. Telemedicine and IT costs were forced lower and enabled a cost-effective process to hugely provide access to 100 million patients located in poorer regions of Colombia, Brazil, Mexico, and Argentina. Education and training have formed the mantra for LATIN and stakeholder development, and ambulance systems development has remained immutable goals.

Results

Almost 800,000 patients were successfully screening through LATIN with a cost for accurate STEMI diagnosis of < $3, a tele accuracy that exceeded 95% and with TTD <4 minutes. A total of 8,440 (1.1%) of patients were diagnosed with AMI in this manner and 3,924 (46.5%) urgently reperfused, mainly with Primary PCI (3,048, 77.8%). D2B times have been lowered now to 51 minutes but this is fortuitous, as several PCI-capable facilities are small, and direct transfer to the catheterization laboratory is easy. Door in and Door out times and transport times remain high as a large number of patients are denied by insurance and other payers for treatment. Overall, mortality is 5.2%.

Conclusions

Global financial and philanthropic institutions should contemplate models analogous to LATIN for saving the lives of millions of poor patients in developing countries from AMI.

3035Synergy of artificial intelligence and single lead EKG to detect and localize STEMI

Background

The cumbersome, standard 12-lead electrocardiogram (EKG) challenges an efficient detection of ST-Elevation Myocardial Infarction (STEMI) in pre-hospital (ambulances) and hospital (portable devices) settings. We believe that our machine-learning algorithm embedded into a single lead EKG will be successful in acute care settings.

Purpose

To incorporate Artificial Intelligence-guided, single lead EKG interpretation, to facilitate easy and accurate STEMI detection in urgent situations.

Methods

This is an observational, retrospective, case-control study. A subset sample was generated from the International Telemedical Systems (ITMS) database that contains cardiologist annotated EKG records. Subset: A total of 2,542 exclusively confirmed STEMI diagnosis EKG records from enrolled healthcare centers in Mexico, Colombia, and Brazil; including specific ischemic heart wall (anterior, inferior, and lateral). Following discharge of treated patients, confirmation of STEMI diagnosis was obtained as feedback from healthcare centers. Records were anonymized EKG that excluded all medical information. Sample: A Standard 12 lead, 10-seconds length, 500Hz sampling frequency EKG was fed to the LUMENGT-AI STEMI detecting algorithm. Preprocessing: Detection of QRS complexes by wavelet system, segmentation of each EKG record into individual heartbeats (total dataset 27,152 beats) with fixed window of 0.4s to the left and 0.9s to the right of main QRS; Classification: A 1-D convolutional neural network was implemented, three classes were considered for individual heartbeats: “Anterior”, “Inferior” and “Lateral”, each corresponding to the heart wall affected. These individual probabilities were aggregated to generate the final label for each of the 12 leads. Training & Testing: 90% and 10% of the dataset was used respectively. Experiments: Intel PC i7 8750H processor at 2.21GHz, 16GB RAM, Windows 10 OS with a NVidia GTX 1070 GPU, 8GB RAM.

Results

Accuracy – Lead V2 (91.7%); Sensitivity Anterior wall – Lead V2 (97.4%); Sensitivity for Lateral wall – Lead I (10.0%); and Sensitivity for Inferior wall – Lead V2 (93.6%).

Conclusions

AI algorithms merged with a Single lead approach detect and localize STEMI within any setting. The V2 lead yields superior results for mapping of ischemic areas of the heart among the anterior and inferior walls. In contrast, diagnosis remains suboptimal for identifying the lateral wall. The usage of synergistic technologies facilitates easy, fast and early STEMI triage and management.

P2426Validating the diagnostic value of a machine learning algorithm for STEMI detection

Background

We have previously reported the use of Artificial Intelligence (AI) guided EKG analysis for detection of ST-Elevation Myocardial Infarction (STEMI). To demonstrate the diagnostic value of our algorithm, we compared AI predictions with reports that were confirmed as STEMI.

Purpose

To demonstrate the absolute proficiency of AI for detecting STEMI in a standard12-lead EKG.

Methods

An observational, retrospective, case-control study. Sample: 5,087 EKG records, including 2,543 confirmed STEMI cases obtained via feedback from health centers following appropriate patient management (thrombolysis, primary Percutaneous Coronary Intervention (PCI), pharmacoinvasive therapy or coronary artery bypass surgery). Records excluded patient and medical information. The sample was derived from the International Telemedical Systems (ITMS) database. LUMENGT-AI Algorithm was employed. Preprocessing: detection of QRS complexes by wavelet system, segmentation of each EKG into individual heartbeats (53,667 total beats) with fixed window of 0.4s to the left and 0.9s to the right of main QRS; Classification: A 1-D convolutional neural network was implemented, “STEMI” and “Not-STEMI” classes were considered for each heartbeat, individual probabilities were aggregated to generate the final label for each record. Training & Testing: 90% and 10% of the sample were used, respectively. Experiments: Intel PC i7 8750H processor at 2.21GHz, 16GB RAM, Windows 10 OS with NVIDIA GTX 1070 GPU, 8GB RAM.

Results

The model yielded an accuracy of 97.2%, a sensitivity of 95.8%, and a specificity of 98.5%.

Conclusion(s)

Our AI-based algorithm can reliably diagnose STEMI and will preclude the role of a cardiologist for screening and diagnosis, especially in the pre-hospital setting.

P5237Continued financial benefits of LATIN telemedicine program from avoiding unnecessary transfer of patients

Background

Latin America Telemedicine Infarct Network (LATIN) employed telemedicine to construct a population-based AMI program in Brazil, Colombia, Mexico, and Argentina. It increased access, accuracy and guidelines-based care and addressed fiscal issues. Previously, we demonstrated a cost and benefit analysis (CBA) of LATIN based upon avoiding unnecessary transfers and hospitalization. We have performed a scrupulous follow up of this initial observation with a long-term follow up from all expanded LATIN sites.

Purpose

To demonstrate that telemedicine avoids unnecessary transfer of patients.

Methods

784,947 patients at LATIN spokes (small clinics in remote areas) were screened and CBA measured at hubs, spokes and telemedicine centers. Technology, transfer, inpatient, and procedure-related costs were included. A sensitivity analysis was performed for worst and best scenarios of costs, revenues, and savings. A comparison with Avera e-Emergency (Sioux Falls, SD) Telemedicine program, involving 85 rural hospitals in 7 states, is provided (13% transfer avoidance).

Results

Of 784,947 screened patients, 8,448 had STEMI (1.08%); 3,911 (46.3%) were urgently reperfused, 3,049 (78%) with PPCI. Time to Telemedicine Diagnosis was 3 min. With efficient triage, costs for non-AMI patients was controlled. LATIN expenses, including for IT and experts, were $272, and for transfer and indirect care, $1,068. Net savings/patient were $796. Savings, till date, range between $187.4 million and $62.4 million (Best scenario −30% transfer avoidance; Worse scenario −10% transfer avoidance).

Conclusions

Longitudinal analysis firms the trend of enormous cost savings with LATIN. Telemedicine avoids unnecessary transfers and hospitalization and it is a cost-effective strategy for population-based AMI programs.

P1741Hitting the wall in converting diagnosed ST-elevation myocardial infarction patients to treating them: a humbling analysis from LATIN telemedicine

Background

The behemoth telemedicine program, Latin America Telemedicine Infarct Network (LATIN) has exponentially grown in 4 countries in Central and South America. It has provided AMI coverage to >100 million patients and it has contributed to transforming AMI care in the continent by its “halo” effect. We continue our meticulous search in evaluating the impact of LATIN and in doing so, we have confronted a sobering reality.

Purpose

To make continued improvements in population-based AMI management, the continued success of the initiative requires participation from healthcare policy makers, health economists, and payers.

Methods

LATIN was created as a hub and spoke model to hugely increase access (>100 million population coverage) to quality AMI treatment primarily with short door to balloon time (D2B) PCI. Innovative telemedicine platforms were created and networked at all 350 centers that were located in small clinics and primary health centers in poor sections of the countries (spokes) and at 24/7 PCI capable institutions (hubs). Remote cardiologists, located in 3 central locations, provided immediate EKG diagnosis (time to telemedicine diagnosis, TTD <3.5 minutes) and they provided expert guidance for the entire STEMI process, Door in Door Out (DIDO), and transport times (TT). LATIN performance metrics, under its strict control, and including process metrics at the hubs, spokes, and at the command telemedicine sites, were measured and plotted. The macroeconomic variables of insurance approvals, ambulance structure, and availability of ICU beds were determined and incorporated into performance variables of the LATIN program.

Results

784,395 patients were screened at 350 LATIN centers (Brazil 143, Colombia 118, Mexico 82, Argentina 7). With expanded reach, 8,440 (1.08%) patients were diagnosed and 3,924 (46.5%) urgently reperfused, including 3,048 (77.7%) with PCI. Time to Telemedicine Diagnosis (TTD) was 3 min, tele-accuracy 98.9%, D2B 51 min, and in-hospital mortality 5.2%. Over 4 years of operation, the proportion of reperfused STEMI patients has ranged between 41–48% - the major reasons for non-treatment were insurance, lack of ICU beds and delayed presentation.

Conclusions

Sustained improvements, as a result of stringent QA processes and continuous education, have resulted in reduced D2B, TTD, DIDO, TT, and in overall mortality. However, LATIN remains constrained with a large proportion of patients that are diagnosed but not treated, largely because of payer denials. Although this metric is showing improvement from broad dissemination of LATIN benefits, further gains from LATIN will result mainly from improved reimbursements.

Abstract OT2-04-01: Phase III trial to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to whole breast RT post breast-conserving surgery (BCS) reduces invasive breast cancer recurrence-free interval (IBCR-FI) in patients (pts) with pathologically positive axillary (PPAx) nodes who are ypN0 after neoadjuvant chemotherapy (NC): NRG Oncology/NSABP B-51/RTOG 1304

This phase III post-NC trial evaluates if CWRNRT post-Mx or whole breast irradiation (WBI) with RNRT after BCS significantly reduces the IBCR-FI rate in pts with PPAx nodes that are pathologically negative after NC. Secondary aims are OS, LRR-FI, DR-FI, DFS-DCIS, second primary cancer, and comparison of RT effect on cosmesis in reconstructed Mx pts. Correlative science examines RT effect by tumor subtype, molecular outcome predictors for residual disease, and predictors for the degree of reduction in loco-regional recurrence.

Methods: Clinical T1-3, N1 IBC PPAx nodes (FNA or core needle biopsy) pts complete ≥8 weeks of NC (anthracycline and/or taxane). HER2+ pts receive anti-HER2 therapy. Following NC, BCS or Mx, sentinel node biopsy (≥2 nodes) and/or Ax dissection with histologically negative nodes is performed. ER/PR and HER-2neu status before NC is required. Pts may receive appropriate adjuvant systemic therapy. Radiation credentialing with a facility questionnaire/case benchmark is required. Random assignment for Mx pts is to no CWRNRT or CWRNRT and for BCS pts to WBI or WBI+RNRT.

Statistics: 1,636 pts are to be enrolled over 5 yrs (definitive analysis at 7.5 yrs). Study is powered at 80% to test that RT reduces the annual hazard rate of events for IBCR-FI by 35% for an absolute risk reduction of 4.6% (5-yr cumulative rate). Intent-to-treat analysis with 3 interim analyses (43, 86, and 129 events) and a 4th/final analysis at 172 events. Pt-reported outcomes focusing on RT effect will be provided by 736 pts before random assignment and at 3, 6, 12, and 24 mos. Accrual as of 6-21-18 is 967 (59.11%).

Contacts: Protocol: CTSU member website https://www.ctsu.org. Questions: NRG Oncology Pgh Clin Coord Dpt: 1-800-477-7227 or ccd@nsabp.org. Pt entry: OPEN at https://open.ctsu.org or the OPEN tab on CTSU member website.

NCT01872975

Support: U10 CA-2166; -180868, -180822; 189867; Elekta

Citation Format: Mamounas EP, Bandos H, White JR, Julian TB, Khan AJ, Shaitelman SF, Torres MA, Vicini FA, Ganz PA, McCloskey SA, Paik S, Gupta N, Li XA, DiCostanzo DJ, Curran WJ, Wolmark N. Phase III trial to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to whole breast RT post breast-conserving surgery (BCS) reduces invasive breast cancer recurrence-free interval (IBCR-FI) in patients (pts) with pathologically positive axillary (PPAx) nodes who are ypN0 after neoadjuvant chemotherapy (NC): NRG Oncology/NSABP B-51/RTOG 1304 [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-04-01.

Ivermectin does not interfere with seminal and hormonal parameters in male rabbits

Ivermectin (IVM) is a macrocyclic lactone used as a broad spectrum antiparasitic agent against nematodes and arthropods. It is mainly used in the control of parasitic infections of domestic animals, and recently has been used in humans to treat onchocerciasis, scabies, and pediculosis. In mammals, evidence has indicated that macrocyclic lactones interact with gamma-aminobutyric acid (GABA)-mediated chloride channels. The GABAergic system is known to be involved in the manifestation of sexual behavior, and previous studies have shown that IVM impaired sexual behavior in both male and female rats. Thus, considering that IVM may interfere with the sexual sphere, this study evaluated the temporal (1 up 60 days) effects of exposure to IVM (0.2 and 1.0 mg/kg, administered subcutaneously) on seminal and hormonal parameters of male rabbits. In male rabbits, the spermatozoa concentration, motility and morphology, the integrity of the plasmatic, acrosomal and mitochondrial membranes of the spermatozoa, the organ weights, gonadosomatic index, serum testosterone concentrations, histopathological findings were evaluated and hematological and serum biochemical analysis was conducted. No changes were observed in male seminal parameters evaluated by spermatozoa concentration, motility, and morphology, nor the potential for fertilization evaluated by the integrity of the plasmatic, acrosomal, and mitochondrial membranes of the spermatozoa; there was also no interference in serum testosterone concentration, serum biochemistry and hematological parameters. The findings of this study using the artificial vagina for collection of semen and computer-assisted semen analysis showed that IVM at doses of 0.2 and 1.0 mg/kg of SC did not alter any of the semen parameters of rabbits evaluated for up to 60 days after administration.

Absence of seminal plasma from sperm-rich fraction decreases boar sperm quality characteristics during the course of liquid storage

Seminal plasma (SP), the fluid that surrounds the sperm cells, is known to exert substantial influence on sperm physiology. The SP has a pivotal role in sperm function in vivo, and due to its components, it functions in an ambiguous manner in vitro, simultaneously possessing deleterious and beneficial effects. This experiment aimed to describe the differences between the presence or absence of SP from the sperm-rich fraction on some spermatozoa characteristics (kinetics, plasma and acrosome membrane integrity, lipid peroxidation and capacitation-like changes). Furthermore, this experiment focused on distinguishing the effects of SP on the variables evaluated from the effects of centrifugation during SP removal. Total and progressive sperm motility, as well as integrity of plasma and acrosome membranes, were less (P <  0.05) in the absence of SP. Membrane lipid peroxidation (P <  0.05) and sperm membrane stability (P < 0.05) did not differ among treatments. The SP from the sperm-rich fraction is important for the maintenance of adequate structural and functional characteristics of extended liquid boar semen and should be present in seminal doses throughout storage. Furthermore, the detrimental effect on the variables evaluated was caused solely by the absence of SP and not by the process of removal through centrifugation at 500 x g for 10 min.

Depressive symptoms and inflammation are independent risk factors of fatigue in breast cancer survivors

BACKGROUND

Psychosocial and inflammatory factors have been associated with fatigue in breast cancer survivors. Nevertheless, the relative contribution and/or interaction of these factors with cancer-related fatigue have not been well documented.

METHOD

This cross-sectional study enrolled 111 stage 0-III breast cancer patients treated with breast surgery followed by whole breast radiotherapy. Fatigue was measured by the total score of the Multidimensional Fatigue Inventory-20. Potential risk factors included inflammatory markers (plasma cytokines and their receptors and C-reactive protein; CRP), depressive symptoms (as assessed by the Inventory of Depressive Symptomatology-Self Reported), sleep (as assessed by the Pittsburgh Sleep Quality Index) and perceived stress (as assessed by the Perceived Stress Scale) as well as age, race, marital status, smoking history, menopause status, endocrine treatment, chemotherapy and cancer stage. Linear regression modeling was employed to examine risk factors of fatigue. Only risk factors with a significance level <0.10 were included in the initial regression model. A post-hoc mediation model using PROCESS SPSS was conducted to examine the association among depressive symptoms, sleep problems, stress, inflammation and fatigue.

RESULTS

At 1 year post-radiotherapy, depressive symptoms (p<0.0001) and inflammatory markers (CRP: p = 0.015; interleukin-1 receptor antagonist: p = 0.014; soluble tumor necrosis factor receptor-2: p = 0.009 in separate models) were independent risk factors of fatigue. Mediation analysis showed that depressive symptoms also mediated the associations of fatigue with sleep and stress.

CONCLUSIONS

Depressive symptoms and inflammation were independent risk factors for cancer-related fatigue at 1 year post-radiotherapy, and thus represent independent treatment targets for this debilitating symptom.

Seminal plasma arising from the whole boar sperm-rich fraction increases the stability of sperm membrane after thawing

Boar spermatozoa arising from the sperm-rich ejaculate fraction are reported to have a more stable plasma membrane and are more resistant to cold shock and premature acrosome reaction than spermatozoa from the whole ejaculate. Furthermore, seminal plasma (SP) can increase the cryotolerance of boar spermatozoa, and in other domestic species, it has the ability to reverse cryopreservation damage. This study aimed to evaluate the effects of boar SP arising from the whole sperm-rich ejaculate fraction (SP-SRF) on the integrity, stability, and peroxidation of sperm membranes after thawing. Each ejaculate ( = 24) was divided among 4 treatments: control (CT), centrifuged and suspended in autologous SP-SRF (CS), centrifuged with withdrawn SP-SRF (CW), and post-thawed SP arising from the whole sperm-rich fraction addition to CW (CWSP). After thawing, all treatments were incubated for 5, 60, and 120 min and were analyzed for membrane integrity, fluidity, and peroxidation by flow cytometer. The absence of SP-SRF increased the lipid disorder ( < 0.05) but had no effect on lipid peroxidation ( > 0.05) or membrane integrity ( > 0.05). However, the increase in lipid disorder by withdrawal of SP-SRF was reversed by SP-SRF addition ( < 0.05) to the post-thawing medium, whereas plasma and acrosomal membrane integrity ( > 0.05) and lipid peroxidation ( > 0.05) were unchanged. In conclusion, despite the centrifugation effects, the addition of SP arising from the whole sperm-rich fraction to post-thawed boar semen decreased sperm lipid disorder without an influence of the sperm membrane integrity and peroxidation.

Abstract P1-10-07: Prospective longitudinal study of epidermal thickening in breast cancer patients treated with conventional versus hypofractionated radiotherapy

Purpose: We conducted two prospective longitudinal studies of epidermal thickening in breast cancer (BRCA) patients treated with either conventional (CRT) or hypofractionated radiotherapy (HRT) using ultrasound images to objectively measure radiotherapy (XRT)-induced skin changes. Methods: Following breast conserving surgery, 105 consenting Stage 0-IIIA BRCA patients were enrolled on two studies of whole breast XRT without regional nodal irradiation. In the first, 66 subjects were treated with conventional fractionation (50 Gy plus a sequential 10 Gy boost at 2 Gy per fraction). In the second, subsequent study, 39 patients with characteristics under-represented in trials of HRT were treated to 39.9 Gy at 2.66 Gy per fraction with a simultaneous integrated boost of 8.1 Gy at 0.54 Gy per fraction. Inclusion criteria for this trial included breast separation &gt;25cm, age &lt;50 years, chemotherapy treatment, or non-Caucasian race. Prior to XRT, the last week of XRT, and 12 weeks and 1 year post XRT, subjects underwent objective ultrasound measurements of epidermal thickness over all four quadrants of the treated breast. A skin thickness ratio (STRA) was generated normalizing for corresponding measurements taken of the untreated breast. Pertinent patient, tumor, and treatment characteristics were collected at all time points, as well as peripheral blood for gene expression assays and assessment of inflammatory markers. Results: HRT patients were significantly younger than CRT patients [mean age 52 (38-73) versus (vs.) 56 years (26-75), p=0.03]. There were no other significant differences in patient, tumor, or treatment characteristics. Baseline measurements indicated 68% of CRT (mean increase 27%, SD 0.30) vs. 71% of HRT patients (mean increase 23%, SD 0.29) had skin thickening in the treated versus untreated breast prior to XRT (p=0.50). At all subsequent time points, CRT patients had significantly higher mean STRA than HRT patients [1.53, SD 0.48 vs. 1.33, SD 0.34 during RT (p=0.03); 1.62, SD 0.48 vs. 1.31, SD 0.45 at 12 weeks post RT (p=0.002); and 1.45, SD 0.39 vs. 1.27, SD 0.40 at 1 year post RT (p=0.03), respectively]. At 1 year, 31% of CRT and 38% of HRT patients had an STRA which was either less than or equal to baseline, indicating full recovery. In multivariable analysis, baseline STRA (p&lt;0.001), BMI (p=0.002), chemotherapy (p=0.004) and CRT treatment (p=0.02) predicted for higher STRA 1 year post XRT. Dmax and breast volume receiving 107% of the dose did not predict for STRA. Gene ontology analysis revealed an over-representation of genes, differentially regulated among patients with high and low STRA, involved in the immune and defense responses. Tumor necrosis factor 2 receptor levels were also significantly higher in CRT than HRT treated patients at 1 year (p=0.03). Conclusions: Our findings indicate that CRT is associated with higher and more severe changes in STRA up 1 year after XRT than HRT, even among patients perceived to be at high risk for XRT-induced skin toxicity and who were not well-represented in the original HRT trials. An increase in peripheral markers of inflammation may be one mechanism by which CRT, BMI, and chemotherapy are associated with higher STRA 1 year post XRT.

Citation Format: Torres MA, Yang X, Mister D, Ali A, Kahn S, Liu T. Prospective longitudinal study of epidermal thickening in breast cancer patients treated with conventional versus hypofractionated radiotherapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-10-07.

Abstract OT2-03-01: NRG oncology/NSABP B-51/RTOG 1304: A phase III superiority clinical trial designed to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to breast RT post breast-conserving surgery (BCS) will reduce invasive cancer events in patients (pts) with positive axillary (Ax) nodes and convert to ypN0 after neoadjuvant chemotherapy (NC)

Background:

This phase III post-NC trial evaluates if CWRNRT post Mx or whole breast irradiation (WBI) with RNRT after BCS significantly reduces the invasive breast cancer recurrence-free interval (IBC-RFI) rate in pts presenting with positive Ax nodes that are pathologically negative after NC. Secondary aims are OS, LRRFI, DRFI, DFS-DCIS, and second primary cancer, as well as comparing RT effect on cosmesis in reconstructed Mx pts.

Correlative science studies examine RT effect by tumor subtype, molecular outcome predictors for residual disease pts, and predictors for the degree of reduction in loco-regional recurrence.

Methods:

Clinical T1-3, N1 IBC pts with positive Ax nodes (FNA or core needle biopsy) complete ≥8 wks of NC (anthracycline and/or taxane). HER2-positive pts receive anti-HER2 therapy (tx). After NC, BCS or Mx is performed with a sentinel node biopsy (≥2 nodes) and/or Ax dissection with histologically negative nodes. ER/PR and HER2 neu status before NC is required. Pts receive required systemic tx. Radiation credentialing with a facility questionnaire and a case benchmark is required. Randomization for Mx pts is to no CWRNRT or CWRNRT and for BCS pts to WBI or WBI+RNRT.

Statistics:

1636 pts to be enrolled over 5 yrs with definitive analysis at 7.5 yrs. Study is powered at 80% to test that RT reduces the annual hazard rate of events for IBCR-FI by 35% for an absolute risk reduction in the 5-yr cumulative rate of 4.6%. Intent-to-treat analysis with 3 interim analyses at 43, 86, and 129 events, with a 4th/final analysis at 172 events will occur. Accrual as of 6/13/16 is 356. Pt-reported outcomes focusing on RT effect will be obtained from 736 pts before randomization and at 3, 6, 12, and 24 months.

Contacts:

Protocol: CTSU member website https://www.ctsu.org. Questions: NRG Oncology Pgh Clin Coord Dpt: 1-800-477-7227 or ccd@nsabp.org. Pt entry: OPEN at https://open.ctsu.org or the OPEN tab on CTSU member website.

Support: U10 CA-2166; -180868, -180822; -189867; Elekta.

Citation Format: Mamounas EP, Bandos H, White JR, Julian TB, Khan AJ, Shaitelman SF, Torres MA, Vicini FA, Ganz PA, McCloskey SA, Paik S, Gupta N, Li XA, DiCostanzo DJ, Curran, Jr WJ, Wolmark N. NRG oncology/NSABP B-51/RTOG 1304: A phase III superiority clinical trial designed to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to breast RT post breast-conserving surgery (BCS) will reduce invasive cancer events in patients (pts) with positive axillary (Ax) nodes and convert to ypN0 after neoadjuvant chemotherapy (NC) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-03-01.

64 COULD FROZEN–THAWED BOAR-SEMEN FERTILITY BE INCREASED WITH SEMINAL PLASMA ADDITION?

Post-thawed addition of seminal plasma (SP) in equine cryopreserved semen increased the integrity of plasma and acrosomal membranes (Andrade et al. 2011 Reprod. Dom. Anim. 46, 682–686) and these possibly affect sperm lifespan, improving fertility (Garcia et al. 2010 Anim. Reprod. Sci. 119, 160–165). This study was conducted to verify the pregnancy (PR) and fertility rate (FR) of addition of homologous SP in thawed boar semen. First, SP collections were made with polled sperm rich-fraction. Semen was centrifuged (500 × g for 10 min) and supernatant was removed, centrifuged one more time (2500 × g for 30 min), vacuum filtered through membranes (0.22 μm), and stored at –80°C for future use. Samples collected to frozen were pooled and divided in 2 aliquots, control (cryopreserved with SP; CON) and cryopreserved without SP (WSP; SP was removed and discarded after centrifugation – 500 × g for 10 min). Samples were extended in freezing extender (Botupharma®) to a final concentration of 300 × 106 spermatozoa per milliliter, packaged in 0.5-mL straws, and frozen in an automatic system (TK Tecnologia em Congelação®) using a rate of –0.5°C min–1 until 5°C, –20°C min–1 until –120°C, and then immersed in LN (–196°C). Ten straws, from each treatment, were thawed in water bath (37°C/30 s) and extended in Beltsville thawing solution to obtain 1.5 × 109 sperm in 40 mL. The other 10 straws of WSP were thawed and extended in Beltsville thawing solution plus 10% (v:v) of SP to originate treatment TSP (thawed added of seminal plasma). Thirty-three (11 per treatment) gilts had synchronized ovulation with altrenogest (25 mg/5 mL, Regumate®) administration per 18 days. Following day after withdrawal the altrenogest was administered with an intramuscular injection of 600 IU of eCG (Novormon®) and 2.5 mg of pLH (Lutropin®-V) after 72 h; a single deep intrauterine insemination was made 36 h after. Five days after, females were slaughtered and embryos were collected (by oviducts flushed) and evaluated by esteromicroscopia. Fertility rate and PR were analysed by SAS program (SAS Institute Inc., 2010, Cary, NC, USA). Fertility rate was analysed by Mixed models, and treatment effects were analysed by orthogonal contrasts (C1: effect without SP = CW v. NC; C2: effect of post-thawed addition of SP = CP v. CW), and PR was evaluated by binary distribution with PROC GLIMMIX test. Fertility rate was not affected (P > 0.05) by cryopreservation of boar semen in presence or absence of SP nor by its addition in Beltsville thawing solution (10.58 ± 3.92, 9.57 ± 4.92, 21.29 ± 7.37 for CON, WSP, and TSP, respectively). Treatments did not influence (P > 0.05) PR (50.00, 36.36, 72.73 for CON, WSP, and TSP, respectively). Thus, neither SP addition in thawed boar semen nor cryopreservation with or without SP can be beneficial to PR and FR, in our experimental conditions. However, a numeric large difference was observed. Therefore, these results lead us to believe that SP have a potential to increase the fertility and pregnancy rate, and that can be verified in further studies, with more repetitions.Research was supported by Agroceres Multimix, Botupharma and FAPESP process 2013/08070-8 and 2011/23484-8.

17 TESTICULAR HISTOPATHOLOGICAL CHARACTERISTICS OF RAMS TREATED WITH LOW-LEVEL LASER THERAPY: PRELIMINARY RESULTS

Testicular degeneration is caused by the loss of testicular thermoregulation induced by high environmental temperature, reproductive disruptions, fever, and others processes. Low-level laser therapy (LLLT) is an important tool to induce cellular proliferation and to stimulate mitosis. This biostimulatory effect was observed in the seminiferous epithelium of rats treated with LLLT, obtaining better results using a cumulative dose of 28.05 J cm–2 rather than 46.80 J cm–2 (Taha and Valojerdi 2004 Lasers Surg. Med. 34, 352–359). Thus, the aim of this study was to evaluate the effect of different LLLT protocols on testes histopathological characteristics of rams submitted to scrotal insulation for the induction of the testicular degeneration. For this, 6 rams were divided in 3 groups: (1) control, without LLLT treatment (n = 2); (2) LLLT treatment with a cumulative dose of 28 J cm–2 (n = 2); and (3) LLLT treatment with a cumulative dose of 56 J cm–2 (n = 2). Treatment was performed once a day and repeated every 48 h during a 15-day interval in the treated groups (2 and 3). The output power used was the same for the treated groups (30 mW). Scrotal insulation was done in all rams at 72 h before the beginning of the treatment period. The rams were castrated after 35 days of scrotal insulation. Both testes were divided in 3 parts: ventral, medium, and dorsal. The testes segments were fixed using Bouin fluid and stained using hematoxylin-eosin. Analyses were performed by light microscopy (model 80i; Nikon, Tokyo, Japan) using the NIS-Elements AR® to measure the lumen of the seminiferous tubules and the seminiferous tubules total area. Ten different areas of each testicular segment were analysed and, in each area, 2 seminiferous tubules were chosen randomly. For this analysis, the percentage of the lumen area of the seminiferous tubule in relation to the total area of the seminiferous tubule (lumen/lumen + tubule) was determined. In parallel, degree of degeneration was classified by blind analysis, as light, moderate, or severe, in each testicular segment. The data was analysed employing SAS (SAS Institute Inc., Cary, NC, USA). The treatment effect was tested using PROC GLM (ANOVA). Tukey's test was used to compare the averages. A treatment effect (P < 0.001) was observed. Group 2 (14.55 ± 2.08%) presented a lower percentage of lumen than did group 1 (36.78 ± 3%) and 3 (30.98 ± 2.24%). The degeneration degree of ram testes of group 1 was classified as moderate for 1 ram and severe for the other, whereas, in group 2, it was classified as light for both rams. For group 3, it was classified as moderate for both rams. Thus, it is possible to conclude that LLLT treatment is efficient, and that the cumulative dose of 28 J cm–2 is more efficient than the cumulative dose of 56 Jcm–2, a corroboration of previous results in rats (Ibid.). However, the results are preliminary and more studies are being done by our group. The authors acknowledge FAPESP processes 2012/00040-0 and 2011/16744-3.

Abstract P3-15-07: Cutaneous toxicity and recovery: Is there a difference between breast cancer patients treated with daily radiotherapy in the morning versus the afternoon?

Background: The human body is most immunologically primed to respond to injury one hour after awakening when peak cortisol levels are achieved. Previous studies have shown that acute stressors like surgery induce a redistribution of immune cells within the body and immediate leukocyte trafficking to the skin in response to cutaneous injury. When surgery is performed during peak cortisol levels (AM), recovery is significantly shorter due to the rapid immunologic response. However, no study has assessed whether the timing of daily radiotherapy (RT) treatment (AM vs. PM) impacts cutaneous healing in breast cancer patients undergoing whole breast RT. The purpose of this study is to compare cutaneous toxicity and recovery in breast cancer patients treated in the morning vs. those treated in the afternoon with standard breast RT.

Methods: Forty post-lumpectomy breast cancer patients were enrolled in a prospective, longitudinal ultrasound imaging study to objectively quantify RT-induced cutaneous toxicity and recovery. Twenty-two women received treatment before 9am and eighteen were treated after 3pm for the duration of their treatment course. All subjects received standard whole breast RT (50 Gy plus a 10 Gy boost in 30 total fractions). Patients were assessed 1 week prior to RT (baseline, T1), week 6 of RT (T2), and 6 weeks (T3), 3 months (T4), 6 months (T5) and 1 year (T6) post-RT. All four quadrants of the affected and unaffected breast were imaged with a 10-MHz ultrasound. Epidermal thickness was measured as a proxy for cutaneous toxicity. A skin thickness ratio (STRA) was generated by normalizing the epidermal thickness measurements to the corresponding contralateral breast measurements. RT-induced skin toxicity was assessed by measuring the change in STRA from baseline to T2, T3, T4, T5 and T6. The recovery time point was determined by identifying the STRA ratio measured after RT most closely approximating that of baseline. Differences in STRA for each patient was assessed at each time point and subsequently compared between patients treated daily before 9am vs. those treated after 3pm.

Results: A total of 138 ultrasound scans were examined. Regardless of treatment time (AM vs. PM), the STRA returned to near normal levels at T6 as indicated by non-significant STRA differences when compared to baseline. Skin thickness change maximized at T5 for the pre-9am group (0.380, 95%CI 0.118-0.641) and at T4 for the post-3pm group (0.487, 95%CI 0.162-0.813). Comparison of STRA changes between subjects treated before 9am and after 3pm showed significantly better recovery at T4 for the morning group (p = 0.049), but were not conclusively different at all other time points.

Conclusions: This study is the first of its kind to objectively document the development of skin toxicity in breast cancer patients treated with daily RT in the AM vs. PM using quantitative ultrasound. Our findings suggest that morning treatment with RT may result in less skin toxicity 3 months post-RT but timing of daily RT did not impact cutaneous toxicity during RT or recovery by 6 months and 1 year post-RT. Further investigation is warranted with a larger cohort and consistent follow up to better ascertain the effect size.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-15-07.

Spectrophotometer and ultrasound evaluation of late toxicity following breast-cancer radiotherapy

PURPOSE

Radiation-induced normal-tissue toxicities are common, complex, and distressing side effects that affect 90% of patients receiving breast-cancer radiotherapy and 40% of patients post radiotherapy. In this study, the authors investigated the use of spectrophotometry and ultrasound to quantitatively measure radiation-induced skin discoloration and subcutaneous-tissue fibrosis. The study's purpose is to determine whether skin discoloration correlates with the development of fibrosis in breast-cancer radiotherapy.

METHODS

Eighteen breast-cancer patients were enrolled in our initial study. All patients were previously treated with a standard course of radiation, and the median follow-up time was 22 months. The treated and untreated breasts were scanned with a spectrophotometer and an ultrasound. Two spectrophotometer parameters-melanin and erythema indices-were used to quantitatively assess skin discoloration. Two ultrasound parameters-skin thickness and Pearson coefficient of the hypodermis-were used to quantitatively assess severity of fibrosis. These measurements were correlated with clinical assessments (RTOG late morbidity scores).

RESULTS

Significant measurement differences between the treated and contralateral breasts were observed among all patients: 27.3% mean increase in skin thickness (p < 0.001), 34.1% mean decrease in Pearson coefficient (p < 0.001), 27.3% mean increase in melanin (p < 0.001), and 22.6% mean increase in erythema (p < 0.001). All parameters except skin thickness correlated with RTOG scores. A moderate correlation exists between melanin and erythema; however, spectrophotometer parameters do not correlate with ultrasound parameters.

CONCLUSIONS

Spectrophotometry and quantitative ultrasound are objective tools that assess radiation-induced tissue injury. Spectrophotometer parameters did not correlate with those of quantitative ultrasound suggesting that skin discoloration cannot be used as a marker for subcutaneous fibrosis. These tools may prove useful for the reduction of radiation morbidities and improvement of patient quality of life.

A prospective study of cancer-related fatigue in women undergoing radiotherapy for breast cancer

110

Background: To investigate potential risk factors for cancer-related fatigue in women with breast cancer undergoing whole-breast radiotherapy (RT), we assessed the contribution of chemotherapy (CTX), RT-induced epidermal thickening, and inflammatory mediators to post RT fatigue.

Methods: Following lumpectomy, 30 women received whole breast RT (50 Gy plus a 10 Gy boost). Prior to RT, at week 6 of RT, and 6 weeks post RT, subjects completed a validated questionnaire assessing fatigue (Multidimensional Fatigue Inventory [MFI-20]). At the above visits, patients underwent blood sampling for inflammatory mediators. In addition, breast epidermal thickness was measured using ultrasound tissue characterization.

Results: Fatigue scores in the sample as a whole did not increase during RT. Independent multivariate analyses of clinical and demographic factors revealed that prior CTX (p<.001) and age <50 (p=.03) were significant predictors of higher post RT fatigue scores. Before, during, and after RT, CTX-treated patients had significantly higher mean fatigue scores than non-CTX-treated subjects. For example, mean MFI scores post RT in patients previously treated with CTX (n=15) were 28 points higher than patients not treated with CTX (mean 61 vs. 33, p<.001), with a clinically meaningful difference being 10 points. Race, cancer stage, and epidermal thickening (defined as a 50% increase over baseline during or after RT, n=17) did not predict higher post RT fatigue scores. Of the inflammatory mediators, plasma IL-6 prior to RT was the strongest predictor of post RT fatigue (p=.02). In addition, plasma IL-6 concentrations prior to RT were significantly higher in patients who received CTX versus those who did not (mean 5.0 vs. 2.5, p=.01). IL-6 prior to RT was also significantly correlated with RT-induced epidermal thickening (p=.04).

Conclusions: Our study suggests that CTX-induced inflammation, measured by plasma IL-6, is independently associated with the development of fatigue as well as epidermal thickening in women undergoing breast RT. Treatments targeting inflammation before RT may reduce both fatigue and epidermal thickening post RT, particularly in patients who have been previously been treated with CTX.

Time interval as a quality measure: What is our baseline prior to nurse navigator implementation?

208

Background: There are various outcome measures to evaluate the quality of multidisciplinary care for breast cancer patients. The National Consortium of Breast Centers defines quality of breast cancer care as accurate evaluation and appropriate services in a timely manner. In a tertiary academic center a diverse referral pattern possibly influences time to treatment. We choose to examine two outcome measures before the start of a nurse navigator: Time from initial diagnosis to first consultation and if the pretreatment consultation for those receiving neoadjuvant chemotherapy or hormonal therapy included all subspecialists.

Methods: Electronic medical records of female patients with breast cancer seen during January-June 2010 were reviewed. Patients with stage IV breast cancer were excluded.

Results: 150 patients were divided into 4 categories: external pathology consult (B1), internally diagnosed with a primary care physician (PCP) at our institution (B2), evaluated by a surgical oncologist before the biopsy (B3), and internally diagnosed with PCP outside of the institution (B4). For B2, B3 and B4 we examined the time intervals to first surgical oncology appointment after diagnosis as shown in the table. For all patients (n=10) who received neoadjuvant therapy, 1 patient saw a surgical oncologist, medical oncologist and radiation oncologist, 9 patients saw 2 subspecialties prior to initiation of first treatment.

Conclusions: Patients are seen within an average of 2 weeks whether they are diagnosed internally (B2, B3) or externally (B4). The group seen by a surgical oncologist prior to biopsy (B3) were seen sooner. For the patients receiving neoadjuvant therapy, 10% saw all 3 specialties prior to initiation of therapy. In July 2010 a nurse navigator was added to the care team. With this new position, our goal is to decrease the time from biopsy to visit by 33% and have 100% of patients receiving neoadjuvant therapy evaluated by all 3 specialists prior to treatment. Our intent is to quantify the effect of a nurse navigator in a large academic center as a quality metric in improving care.

[Table: see text]

Patterns of locoregional failure following radiotherapy for breast cancer

118

Background: To determine the influence of radiotherapy (XRT) technique on local control in breast cancer (BRCA) patients, we evaluated the relationship between PET/CT-identified locoregional recurrences (LRR) and prior definitive XRT treatment plans.

Methods: Twenty-two consecutive LRRs of BRCA were identified by PET/CT in 19 patients treated from 2004-2011 with definitive post-operative radiation for their BRCA. PET/CT and original XRT CT simulation images were fused using a B-spline deformable registration algorithm (VelocityAI, Velocity Medical Solutions, Atlanta, GA) to correct for posture and soft tissue changes. Prior XRT dose to the FDG avid LRR region was calculated. LRR was classified as in-field, marginal or out-of-field. In-field LRRs were defined as ≥95% of the LRR volume receiving ≥95% of the prescribed dose (45–50.4 Gy). Marginal misses were LRRs at the field edge and/or not receiving ≥95% of the prescribed dose. Out-of-field LRRs were LRRs intentionally not treated with the original XRT plan.

Results: Four LRRs were in-field, 8 were marginal and 10 were out-of-field, with two patients having both in-field and out-of-field LRRs and one having a marginal and out-of-field LRRs. Three in-field, 3 marginal and 6 out-of-field LRRs occurred simultaneously with distant metastasis (DM). In-field LRRs received a median dose of 48.4Gy (range 45-50Gy). Two in-field LRRs were marginal misses of the additional 15 Gy boost dose (median dose received 53.5 Gy); both patients had high grade, ER/PR-, and HER2 + tumors. In the 7 patients with triple negative tumors, there were 4 marginal, 4 out-of-field, and no in-field LRRs. Among marginal LRRs, a median dose of 33Gy (range 2–45.6Gy) was delivered. Out-of-field LRRs occurred in 5 supraclavicular and 5 internal mammary lymph nodes. With a median follow-up period of 3.7 yrs, the 5-yr disease-free survival (DFS) in patients with an isolated LRR is 55.6%, while in those recurring with DM, the DFS is 22.5%.

Conclusions: Our study is one of the first to systematically evaluate the influence of XRT technique over local control in BRCA. Due to the number of marginal and out-of-field LRRs, our data suggest that XRT field design and dose are important factors in preventing LRRs in addition to tumor biology.

Antioxidant therapy attenuates oxidative stress in the blood of subjects exposed to occupational airborne contamination from coal mining extraction and incineration of hospital residues

Coal mining and incineration of solid residues of health services (SRHS) generate several contaminants that are delivered into the environment, such as heavy metals and dioxins. These xenobiotics can lead to oxidative stress overgeneration in organisms and cause different kinds of pathologies, including cancer. In the present study the concentrations of heavy metals such as lead, copper, iron, manganese and zinc in the urine, as well as several enzymatic and non-enzymatic biomarkers of oxidative stress in the blood (contents of lipoperoxidation = TBARS, protein carbonyls = PC, protein thiols = PT, α-tocopherol = AT, reduced glutathione = GSH, and the activities of glutathione S-transferase = GST, glutathione reductase = GR, glutathione peroxidase = GPx, catalase = CAT and superoxide dismutase = SOD), in the blood of six different groups (n = 20 each) of subjects exposed to airborne contamination related to coal mining as well as incineration of solid residues of health services (SRHS) after vitamin E (800 mg/day) and vitamin C (500 mg/day) supplementation during 6 months, which were compared to the situation before the antioxidant intervention (Ávila et al., Ecotoxicology 18:1150-1157, 2009; Possamai et al., Ecotoxicology 18:1158-1164, 2009). Except for the decreased manganese contents, heavy metal concentrations were elevated in all groups exposed to both sources of airborne contamination when compared to controls. TBARS and PC concentrations, which were elevated before the antioxidant intervention decreased after the antioxidant supplementation. Similarly, the contents of PC, AT and GSH, which were decreased before the antioxidant intervention, reached values near those found in controls, GPx activity was reestablished in underground miners, and SOD, CAT and GST activities were reestablished in all groups. The results showed that the oxidative stress condition detected previously to the antioxidant supplementation in both directly and indirectly subjects exposed to the airborne contamination from coal dusts and SRHS incineration, was attenuated after the antioxidant intervention.

Occupational airborne contamination in South Brazil: 2. Oxidative stress detected in the blood of workers of incineration of hospital residues

One of the most useful methods for elimination of solid residues of health services (SRHS) is incineration. However, it also provokes the emission of several hazardous air pollutants such as heavy metals, furans and dioxins, which produce reactive oxygen species and oxidative stress. The present study, which is parallel to an accompanied paper (Avila Jr. et al., this issue), investigated several enzymatic and non-enzymatic biomarkers of oxidative stress in the blood (contents of vitamin E, lipoperoxidation = TBARS, reduced glutathione = GSH, oxidized glutathione = GSSG, and activities of glutathione S-transferase = GST, glutathione reductase = GR, glutathione peroxidase = GPx, catalase = CAT and superoxide dismutase = SOD), in three different groups (n = 20 each) exposed to airborne contamination associated with incineration of SRHS: workers directly (ca. 100 m from the incinerator) and indirectly exposed (residents living ca. 5 km the incineration site), and controls (non-exposed subjects). TBARS and GSSG levels were increased whilst GSH, TG and alpha-tocopherol contents were decreased in workers and residents compared to controls. Increased GST and CAT activities and decreased GPx activities were detected in exposed subjects compared to controls, while GR did not show any difference among the groups. In conclusion, subjects directly or indirectly exposed to SRHS are facing an oxidative insult and health risk regarding fly ashes contamination from SRHS incineration.

Occupational airborne contamination in south Brazil: 1. Oxidative stress detected in the blood of coal miners

Reactive oxygen species and nitrogen species have been implicated in the pathogenesis of coal dust-induced toxicity. The present study investigated several oxidative stress biomarkers (Contents of lipoperoxidation = TBARS, reduced = GSH, oxidized = GSSG and total glutathione = TG, alpha-tocopherol, and the activities of glutathione S-transferase = GST, glutathione reductase = GR, glutathione peroxidase = GPx, catalase = CAT and superoxide dismutase = SOD), in the blood of three different groups (n = 20 each) exposed to airborne contamination associated with coal mining activities: underground workers directly exposed, surface workers indirectly exposed, residents indirectly exposed (subjects living near the mines), and controls (non-exposed subjects). Plasma TBARS were increased and whole blood TG and GSH levels were decreased in all groups compared to controls. Plasma alpha-tocopherol contents showed approximately half the values in underground workers compared to controls. GST activity was induced in workers and also in residents at the vicinity of the mining plant, whilst CAT activity was induced only in mine workers. SOD activity was decreased in all groups examined, while GPx activity showed decreased values only in underground miners, and GR did not show any differences among the groups. The results showed that subjects directly and indirectly exposed to coal dusts face an oxidative stress condition. They also indicate that people living in the vicinity of the mine plant are in health risk regarding coal mining-related diseases.

Antibody-mediated rejection: hyperacute rejection reality in liver transplantation? A case report

Hyperacute rejection is rare among ABO-compatible liver transplantations. The mechanism is donor preformed antibodies causing graft loss within a few days. Herein, we have described a case of an ABO-compatible liver transplantation that underwent hyperacute rejection, needing retransplantation for treatment. A 27-year-old man of blood group A positive who displayed fulminant hepatic failure due to hepatitis B (in agreement with the O'Grady criteria), received an ABO-compatible graft. He developed significant asthenia, fever, hypotension, oliguria, and coagulopathy. Ultrasonography revealed total thrombosis of the portal vein and absence of dilatation of bile ducts. The patient was priorized for retransplantation and underwent a good subsequent evolution. On anatomopathologic exam the explant revealed thrombosis of the intrahepatic branches of the portal vein with venous and ischemic infarcts compatible with a diagnosis of hyperacute rejection. The clinical findings of hyperacute rejection were characterized by progressive elevation of bilirubin and thrombocytopenia associated with signs of hepatic failure during the first days after transplantation. In this case, the histological exam was compatible with hyperacute rejection, excluding the diagnoses of hepatic artery thrombosis or biliary obstruction, despite the negative test for anti-HLA antibodies. The diagnosis of hyperacute rejection could be made associated with a short ischemic time and a good response after retransplantation.

The Systemic Absorption of Etoposide after Intravaginal Administration in Patients with Cervical Intraepithelial Lesions Associated with Human Papillomavirus Infection

PURPOSE

The purpose of this study was to determine the systemic absorption and the release of etoposide in cervical tissue administered via a vaginal ovule to women diagnosed with cervical intraepithelial lesions associated with human papillomavirus (HPV).

METHODS

Fifteen women with low- and high-grade intraepithelial neoplasia confirmed by colposcopic test received a 50-mg intravaginal etoposide dose three times a week for 3 weeks. At the end of the study period, paralleled with the last ovule administered, blood samples were collected over a period of 24 h, and in situ cervical samples were obtained at 3 and 10 h after drug administration. Etoposide concentrations were determined in plasma and in in situ cervical samples using the high-performance liquid chromatography method with electrochemical detection.

RESULTS

Pharmacokinetic analyses of plasma data indicated low or lack of systemic exposure of etoposide after the vaginal administration. Nevertheless, high concentrations of etoposide were found in all in situ cervical samples, indicating that etoposide could be released from its pharmaceutical formulation.

CONCLUSIONS

The results of the study suggest that the etoposide administered as intravaginal ovule is safe and tolerable and apparently could be a suitable option in patients with cervical intraepithelial neoplasia. Clinical results and the true impact on HPV infection and evolution of dysplasia need to be confirmed.

[Effectiveness of venlafaxine in the treatment of alcohol dependence with comorbid depression]

INTRODUCTION

There are no conclusive data on the effectiveness of antidepressant drugs in the treatment of comorbid cases of alcohol dependence and depression.

OBJECTIVES

To determine the effectiveness of venlafaxine on depression and on severity (need of treatment) of alcohol dependence and related problems.

METHODS

Observational, open-label, multicenter, 24-week follow-up study.

PATIENTS

90 outpatients with diagnosis of alcohol dependence and associated major depression disorder (DSMIV criteria).

OUTCOMES MEASURES

the Hamilton Rating Scale for Depression (HAM-D17), European Addiction Severity Index (EuropASI) and Clinical Global Impression, severity and improvement subscales, (CGI-S and CGI-I). Evaluations were performed at baseline and at weeks 2, 4, 8 and 24.

RESULTS

Mean age 44.94+/-9.74 years; 73.3 % man. HAM-D17 mean scores significantly decreased from baseline (24.85+/-5.94) to week 24 (5.976+/-4.68) and at each of the follow-up visits vs previous visit (p < 0.0005). Significant decreases from baseline to week 24 were obtained in four areas of EuropASI: medical status (2.12+/-2.45 to 1.07+/-1.68), alcohol use (5.29+/-2.24 to 3.04+/-2.35), family/ social relationships (3.68+/-2.36 to 1.71+/-2.06) and psychiatric status (5.61+/-1.81 to 2.67+/-2.03). Tolerance was excellent or good in 76.7% of the patients.

CONCLUSIONS

Venlafaxine demonstrated to be effective in the treatment of depressive alcoholic patients. Furthermore, it seems to be useful to decrease the severity of problems related with the alcohol use.

No association between Helicobacter pylori and Mycobacterium tuberculosis infections among gastrointestinal clinic attendees in Lima, Peru

Helicobacter pylori (HP) infection can cause hypochlorhydria, a positive risk factor for Mycobacterium tuberculosis (MTB) infection. This study examined the association between HP and MTB infections among persons attending the Policlinico Peruano Japonés Gastrointestinal Clinic in Lima, Peru. From 23 June 2000 to 18 August 2000, consenting 18-55 year olds who attended the clinic for gastric biopsy gave blood for HP serologic testing, underwent tuberculin skin testing (TST) and completed a social and medical history. Of 128 participating patients, 78 (61%) were TST positive for MTB, and 107 (84%) were infected with HP by serology. Of the patients who were HP positive, 67 (63%) developed positive TST reactions compared to 11 (52%) of 21 HP-seronegative subjects (OR 1.29; 95% CI 0.54-3.11; P = 0.6). There was no association after adjusting for covariates of H. pylori infection (OR 0.78; 95% CI 0.23-2.71; P = 0.7). However, study power was limited by high prevalence of the two infections.

SOCIDROGALCOHOL: the Spanish Scientific Society for the Study of Alcohol, Alcoholism and other Drug Dependencies

Founded in 1969, SOCIDROGALCOHOL is a reference point for professionals interested in drug dependencies, both for Spaniards and for professionals belonging to Spanish-speaking areas. In its 32 years of existence SOCIDROGALCOHOL has spread to all the regions of Spain and most of the Latin-American countries. In the past 5 years SOCIDROGALCOHOL has undergone notable growth, increasing the number of members (from 460 to 816), as well as the number of scientific activities carried out. The National Conferences represent an annual meeting point for the members, where multiple scientific sessions take place, as well as the ordinary general assembly. They are usually held in the spring and last 3 days, with an attendance of around 400 professionals. Within the field of ongoing training, SOCIDROGALCOHOL also carries out other activities: the Autumn School, the Latin-American Virtual Congress of Drug Dependence, distance learning courses, etc. Special mention should be made to the official journal of the Society, Adicciones, founded in 1989. Adicciones is published quarterly in Spanish and its articles are subjected to peer review; 2000 copies of each issue are published. The abstracts can be accessed free on the website of the Society, www.SOCIDROGALCOHOL.org. In this paper the most relevant historical aspects of SOCIDROGALCOHOL will be summarized, along with its current activities and future perspectives.

Influence of season and pollution on the antioxidant defenses of the cichlid fish acará (Geophagus brasiliensis)

The livers of Geophagus brasiliensis collected from both a non-polluted site and a polluted site were analyzed for different antioxidant defenses, O2 consumption, thiobarbituric acid-reactive substance (TBARS) levels, and histological damage. Compared to controls (116.6 +/- 26.1 nmol g-1), TBARS levels were enhanced at the polluted site (284.2 +/- 25.6 nmol g-1), as also was oxygen consumption (86.6 +/- 11.3 and 128.5 +/- 9.8 micromol O2 min-1 g-1, respectively). With respect to enzymatic antioxidants, increased catalase activities (8.7 +/- 1.3 and 29.2 +/- 2.4 mmol min-1 g-1, respectively), unchanged superoxide dismutase activities (767.2 +/- 113.3 and 563.3 +/- 70.2 U g-1, respectively), and diminished glutathione S-transferase activities (29.0 +/- 3.2 and 14.9 +/- 3.2 micromol min-1 g-1, respectively) were detected. Reduced glutathione (1.91 +/- 0.17 and 1.37 +/- 0.25 mM, respectively), oxidized glutathione (1.50 +/- 0.20 and 0.73 +/- 0.17 mM, respectively), and total glutathione (3.40 +/- 0.26 and 2.07 +/- 0.27 mM, respectively) concentrations were also below control values at the polluted site. Nevertheless, the observed ethoxyresorufin-O-deethylase activities (1.34 +/- 0.11 and 16.7 +/- 0.21 pmol min-1 mg-1, respectively) showed enhanced values at the polluted site. The main histological damage observed in the hepatocytes from fish collected at the polluted site was characterized by heavy lipid infiltration. Fish collected at the end of spring showed higher O2 consumption, higher superoxide dismutase and glutathione S-transferase activities, and higher total and oxidized glutathione concentrations compared to the beginning of autumn. No seasonal changes were observed in catalase activities, glutathione or TBARS levels. Fish chronically exposed to relatively high pollution levels seem to be unable to set up adequate antioxidant defenses, probably due to severe injury to their hepatocytes. The higher antioxidant defenses found at the end of spring are probably related to the enhanced activities during high temperature periods in thermoconforming organisms.

Simulium spp. control program in Rio Grande do Sul, Brazil

Insects of the Simuliidae family have been the object of control in Rio Grande do Sul since the 70s. Their constant attacks became a social-economical problem as well as a problem of Public Health, with serious consequences to men and to the economy of the areas in which the insects develop. At first, the control was done with a chemical larvicide Themephos ABATE 500 E, but an imperfect measuring of outflow to determine the quantity of the product made Simulium spp. resistant to it. From 1983 on, following a study of a new method for the outflow measuring, we started to use a biological larvicide Bacillus thuringiensis serovar israelensis based. The biological control uses the new method in 36.4% of the state area, assisting about 3,500,000 inhabitants.

Early-onset type 2 diabetes: metabolic and genetic characterization in the mexican population

The objective of this study was to investigate possible defects in the insulin sensitivity and/or the acute insulin response in a group of Mexican patients displaying early-onset type 2 diabetes and to evaluate the contribution of mutations in three of the genes linked to maturity-onset diabetes of the young. We studied 40 Mexican patients with an age of diagnosis between 20 and 40 yr in which the insulin sensitivity as well as the insulin secretory response were measured using the minimal model approach. A partial screening for possible mutations in 3 of the 5 genes linked to maturity-onset diabetes of the young was carried out by PCR-single strand conformation polymorphism analysis. A low insulin secretory capacity (AIRg = 68.5 +/- 5 muU/mL.min) and a near-normal insulin sensitivity (3.43 +/- 0.2 min/muU.mL x 10(4)) were found in these patients. Among this group we found two individuals carrying missense mutations in exon 4 of the hepatocyte nuclear factor-1alpha (HNF-4alpha) gene (Asp(126)-->His/Tyr and Arg(154)-->Gln, respectively) and one carrying a nonsense mutation in exon 7 of the HNF-1alpha gene (Gln(486)-->stop codon); 7.5% had positive titers for glutamic acid decarboxylase antibodies. Thirty-five percent of cases had insulin resistance; these subjects had the lipid abnormalities seen in the metabolic syndrome. A defect in insulin secretion is the hallmark in Mexican diabetic patients diagnosed between 20 and 40 yr of age. Mutations in either the HNF-1alpha or the HNF-4alpha genes are present among the individuals who develop early-onset diabetes in our population. These particular sequence changes have not been previously reported and therefore represent putative new mutations. Even in the absence of endogenous hyperinsulinemia, insulin resistance is associated with an adverse lipid profile.

[Outbreak of bubonic plague in Jacocha, Huancabamba, Perú ]

Climatic alterations arising in the north of Perú as a result of the El Niño phenomenon (ENSO) have caused variations in the crop volume, changes in the direction of rivers and probably an increase in the rodent population. In February 1999, in a native community in Jacocha, Huancabamba, Piura's mountains, Perú, an outbreak of bubonic plague appeared with five human cases, one of which lead to death. The diagnosis was confirmed by serology (passive hemaglutination). The presence of antibodies in dogs of localities close to Jacocha has confirmed the circulation of Yersinia pestis in the region. The outbreak was controlled by the local sanitary authorities' prompt action. This episode, after an epidemiological silence for more than four years, showed the necessity of intensifying the plague epidemiological surveillance system in this area.

[Iron deficiency anemia in children]

OBJECTIVE: To present the aspects involved in iron deficiency anemia in children and several measures for its control. METHOD: The authors performed an extensive review of national and international literature and associated findings to their own personal experience in this area. The study included general aspects of iron metabolism, iron deficiency, and the mechanisms that trigger iron deficiency anemia (IDA). In addition, the authors focused on the current situation of IDA in Brazil, its prevention and treatment. RESULTS: Iron deficiency is still one of the most serious public health issues in Brazil despite all the available knowledge about intervention measures. The studies found in the literature show excellent results through the fortification of foods and/or iron supplementation, in association with nutritional education. CONCLUSION: The authors concluded that Brazil detains sufficient knowledge regarding IDA, and that the proposed intervention measures have proved to be efficient. There is, however, a lack of political will and focus at all governmental levels (Federal, State and Municipal), and a greater commitment on the part of health professionals that allow the alarming prevalence rates of iron deficiency anemia in our population at higher risk (i.e. children) to be reversed.