Decrease in suicide rates in Brazil during the COVID-19 pandemic

Natural disasters such as public health epidemics may potentially affect suicide rates. The global COVID-19 pandemic poses an unprecedented challenge for healthcare systems and general populations worldwide. In this retrospective ecological study, we aimed to examine any changes in the suicide rates during the COVID-19 pandemic and to assess the relationship between COVID-19 death rates and deaths by suicide in Brazil. Data on suicide and COVID-19 case numbers were extracted from the Ministry of Health agencies and grouped weekly. We performed a time series analysis of suicide rates, a comparison of mean suicide rates between the pre-COVID-19 period and the COVID-19 period, and conducted a Poisson regression to examine the relationship between deaths due to COVID-19 and suicide rates. Our results showed decreased suicide rates during the COVID-19 pandemic. We also found that deaths owing to COVID-19 impact those owing to suicide after 10 weeks in the upward direction; however, we did not observe for enough time to see a change in the suicide rate curve. These findings are fundamental to understand suicidal behaviors in epidemic situations. However, the field needs more studies evaluating the impact of significant public health events on suicidality, incorporating extended follow-up periods.

Comparison of clinical and echocardiographic scores to predict pre-capillary pulmonary hypertension

Funding Acknowledgements

Type of funding sources: None.

Background

Right heart catheterization (RHC) is the gold-standard method to confirm the diagnosis of Pulmonary Hypertension (PH) and to differentiate between pre- and post-capillary PH. However, RHC is an invasive and sometimes low-available procedure, which cannot be performed in all the patients with suspected PH. Clinical and echocardiographic scores have been developed to predict pre-capillary PH. We aimed to compare the performance of four of these scores in a population with suspected PH.

Methods

We retrospectively included consecutive patients who underwent RHC for suspected PH. If the non-invasive evaluation was clearly suggestive of left heart disease, RHC was dispensed being considered not clinically relevant. We also excluded patients with congenital heart disease. We compared the performance of four scores to predict pre-capillary PH: Score 1 (Opotowsky et al.), score 2 (Richter et al.), score 3 (Berthelot et al.) and score 4 (D’Alto et al..

Results

Of the 142 included patients, 76 patients had pre-capillary PH, 42 had post-capillary PH and 24 patients did not meet invasive criteria for PH. We were able to perform the aforementioned scores in the majority of our patients (82% for score 1, 100% for score 2, 98% for score 3 and 83% for score 4). The AUC to predict pre-capillary PH using these scores were 0.74 for score 1, 0.77 for score 2, 0.82 for score 3 and 0.70 for score 4 (p = 0.37). Using the best cut-off points for each score, the score 3 correctly classified the highest percentage of patients (75.5%), with a sensitivity of 92% and a specificity of 60% to predict pre-capillary PH.

Conclusion

Combined clinical and echocardiographic characteristics can be used to predict pre-capillary PH with a fairly good performance. Score 3 (Berthelot et al.) was the score with the highest discrimination power. Validation of these scores in larger cohorts of patients with suspected PH are needed.

Clinical and echocardiographic characteristics Interpretation Opotowsky et al. LA diameter (<32 mm: +1, >24 mm: -1), mid-systolic notch or acceleration time <80 msec (+1), E/e’>10 (-1) Score ≥ 0 has a sens. 100% and a spec. 62% for pre-capillary PH Richter et al. Age > 68 years (+1), BMI > 30 kg/m2 (+1), absence of RV enlargement (+1), LA enlargement (+1) Score >4 predicted post-capillary PH (AUC 0.78) Berthelot et al. Atrial fibrillation (+2), diabetes mellitus (+1), LA enlargement (15 ≤ LAA < 19: +1, 19 ≤ LAA < 24: +2, ≥ 19 cm2: +3), RV end-diastolic area (<27 cm2: +2), LV mass index (46 < LVMI ≤ 62: +1, 62 < LBMI ≤ 81: +2,< 81 cm2: +3) Score <5 ruled out post-capillary PH D’Alto et al E/e" ≤ 10 (+2), dilated non-collapsible IVC (+2), EI ≥ 1.2 (+1), right-to-left heart chamber dimension ratio > 1 (+1), RV forming the heart apex (+1) Score ≥ 2 has a sens. 99% and a spec. 54% for pre-capillary PH (AUC 0.85) Table 1. The clinical and echocardiographic scores evaluated in this study. AUC: area under the curve, EI: eccentricity index, IVC: inferior vena cava, LA: left atrial, LAA: left atrial area, LV: left ventricle, LVMI: left ventricle mass index, PH: pulmonary hypertension, Sens.: sensibility, Spec.: specificity, RV: right ventricle Abstract Figure.

Predictors of survival in patients with precapillary pulmonary hypertension

Funding Acknowledgements

Type of funding sources: None.

Introduction

Although the perceived prognosis of patients with precapillary pulmonary hypertension (PH) is poor, the natural history of this condition is very heterogeneous. In this study we sought to identify predictors of poor outcomes which could help refine prognosis.

Methods

We studied consecutive patients referred to our centre from 12/2016 to 11/2018 with confirmed precapillary PH. A range of clinical, laboratory, echocardiographic and right heart catheterization (RHC) data variables were collected to assess predictors of survival. Outcome was defined as mortality from any cause.

Results

Of the 80 included patients, 51 (64%) were female and mean age was 60.5 ± 16.0 years. The majority of patients (45%) had pulmonary arterial hypertension (group 1) and 41% were chronic thromboembolic pulmonary hypertensive disease patients (group 4). During a median follow-up of 18.7 [IQR 12.3 – 26.7] months, 10 patients (12.5%) died. New York Heart Association (NYHA) functional class (HR 19.4 [95% CI 2.56 - 147.5], p = 0.004) was the strongest predictor of mortality, whereas higher haemoglobin (HR 0.70 [0.49 - 0.99], p= 0.047) and 6-minute walking distance (6MWD) expressed as percentage of predicted (HR 0.96 [0.93 - 0.99], p = 0.004) were associated with better survival overall. Echocardiographic parameters such as eccentricity index (HR 3.35 (95% CI 1.11 - 10.0), p = 0.031), short pulmonary acceleration time (HR 0.98 [95% CI 0.96 - 0.99], p = 0.008), the presence of moderate to severe tricuspid regurgitation (HR 6.46 [95% CI 1.67 - 25.0], p = 0.007) and pericardial effusion (HR 3.86 [95% CI 1.12 - 13.4], p = 0.033) were also associated with death. Traditional right ventricular function parameters such as fractional area change, tricuspid annular plane systolic excursion (TAPSE) and S velocity of the lateral annular tricuspid annulus did not predict mortality in these patients. Invasive pressures and pulmonary vascular resistance measured by RHC were also not associated with mortality. In multivariable analysis, NYHA functional class was the only independent predictor of mortality in patients with precapillary PH (HR 14.5 [95% CI 2.3 - 146.8], p = 0.006).

Conclusion

Eccentricity index, short pulmonary acceleration time, moderate to severe tricuspid regurgitation and pericardial effusion were associated with poor survival. Functional class was the strongest independent predictor of mortality in precapillary PH patients. These parameters may help stratify the risk of death in this heterogenous population.

Diabetes and pre-infarct angina. Time to rethink comorbidities in the reperfusion-injury phenomenon?

Background

Pre-infarct angina (PIA) has been shown to reduce reperfusion injury and infarct size in patients with ST-elevation myocardial infarction (STEMI) and currently represents the most efficient form of myocardial conditioning yet discovered. The role of diabetes on ischemic preconditioning remains controversial – while some pre-clinical studies suggest that diabetes blunts ischemic conditioning, clinical studies are lacking.

Methods

We retrospectively evaluated consecutive patients with STEMI admitted in our hospital from January 2008 to August 2018 who underwent primary angioplasty (PCI). PIA was defined as chest, arm or jaw pain during the preceding 48h before STEMI diagnosis. Peak creatine kinase and peak Troponin T levels were used as a surrogate of infarct size. Ischemic time (IT) was defined as the time between the onset of symptoms to the restoration of flow after either guidewire passage, thrombus aspiration or first balloon inflation.

Results

Of the 1143 included patients, 74% (n=845) were male and mean age was 62.6±13.1 years. A quarter of STEMI-patients had diabetes (25%, n=285). Almost a third of the patients (32%, n=359) had a history of angina in the preceding 48h before STEMI (PIA). The proportion of PIA was similar between diabetic and non-diabetic patients. In patients with diabetes, PIA was associated with lower creatine kinase (CK) (1144 [500–2212] vs 1715 [908–3309] U/L, p=0.0029) and Troponin T (TnT 3.30 [1.90–6.58] vs 4.88 [2.50–9.58] ng/mL, p=0.0022) despite similar IT as compared to those without PIA (328 [200–554] vs. 258 [180–530] minutes, p=0.1365). In non-diabetic patients, PIA was not significantly associated with infarct size (TnT 3.74 [2.23–7.11] vs 4.56 [2.44–7.77] ng/mL, p=0.1945; CK 1549 [910 - 2909] vs 1793 [996 - 3078] U/L, p=0.0653) even after adjustment for the increased ischemic time (240 [150–550] vs. 210 [140–405] minutes, p=0.0128) (β=−0.12, p=0.085 for CK and β=−0.11, p=0.183 for TnT). A significant interaction was observed between the existence of PIA and diabetes on peak TnT (p=0.026 for interaction) and CK (p=0.047 for interaction), which was independent of the culprit vessel and IT. During a median follow-up period of 18.0 [12.1–25.5] months, 268 (24.0%) MACE events have occurred (165 deaths, 27 strokes, 46 myocardial infarctions and 26 target vessel revascularization). PIA was associated with a significant reduction in the incidence of MACE (HR 0.66 (95% CI: 0.48–0.89)) driven by a reduction on mortality (HR 0.44 (95% CI: 0.28–0.70)). Diabetes was associated with an increased incidence of MACE (HR 1.42 (95% CI: 1.07–1.89)). No interaction was found between diabetes and PIA on their effect on MACCE events.

Conclusion

PIA is a strong predictor of favourable outcomes in the setting of STEMI. The effect of PIA on myocardial protection in patients with STEMI undergoing primary PCI seems to be modulated by the presence of diabetes.

Distribution of Peak CK and Peak TnT

Funding Acknowledgement

Type of funding source: None

555 Right ventricular longitudinal strain of patients with pulmonary hypertension

Introduction

Noninvasive echocardiography evaluation of the right ventricle (RV) has been shown to have prognostic value in patients with pulmonary hypertension (PH). Recently, speckle-tracking echocardiography has emerged as a new tool in the RV assessment. In this study, we aimed to study the value of global longitudinal strain in the RV evaluation of these patients.

Methods

We collected clinical, laboratory, echocardiographic and right heart catheterization (RHC) data from consecutive patients referred to an expert tertiary care referral centre from 12/2016 to 11/2018. Global RV systolic peak longitudinal strain (RVS) and RV free wall peak longitudinal strain (RVFWS) (mean of the basal, mid- and apical-segments) were measured by speckle-tracking technique with Echo-Pac software from GE Healthcare®.

Results

Of the 97 included patients, 76% were female. The mean age was 65 ± 15 years. Most patients were in NYHA class II. Median time between TTE and RHC was 70 days [IQR 34 - 184]. Group 2 PH was the most frequent aetiology of PH (35), followed by group 1 (26), group 4 (18), group 5 (3) and group 3 (2). The echocardiographic evaluation of this population showed borderline parameters of RV dysfunction (tricuspid annular plane systolic excursion (TAPSE) 18 ± 4 mm, fractional area change (FAC) 33 ± 10% and S’ tricuspid wave 10 ± 3 cm/sec). Mean RV global strain was -15 ± 5 and RV free wall strain was -17 ± 7.

Both strain parameters significantly correlated with other echocardiographic parameters such as TAPSE, FAC, Tricuspid S wave, RV diastolic diameter, eccentricity index (EI), systolic pulmonary artery pressure (SPAP), pulmonary acceleration time and presence of RV outflow tract notching. Strain parameters were also associated with pulmonary artery pressures and pulmonary vascular resistance (PVR) measured by RHC. Strain parameters did not correlate with PECP (p > 0.05).

In multivariate analysis, RV global longitudinal strain predicted invasive mean pulmonary artery pressure and PVR independently of TAPSE and FAC (β=1.38, p < 0.001). RV global strain > -17.1 predicted PVR > 3 wood (OR 3.46, CI 1.50 - 8.02, AUC 0.72) and PMAP > 20 mmHg (OR 4.92, CI 1.67 - 14.51, AUC 0.78). TAPSE < 18 mm predicted PVR > 3 wood (OR 7.41, CI 2.99 - 18.36, AUC 0.72).

Conclusion

RV global and free wall longitudinal strain significantly correlate with other echocardiographic parameters of RV structure and function and with invasive pulmonary artery pressures and PVR.

Abstract 555 Figure.

P1289 Echocardiograhic prediction of pulmonary arterial capacitance in patients with heart failure with preserved ejection fraction

Background

Pulmonary arterial capacitance (PAC) has emerged as one of the strongest hemodynamic predictors of adverse outcomes in a wide spectrum of cardiovascular diseases, including pulmonary hypertension in heart failure with preserved ejection fraction (HFpEF-PH). We aimed to study non-invasive surrogates for PAC using transthoracic echocardiography in this population.

Methods

We retrospectively evaluated consecutive patients referred to an expert tertiary care referral centre from December 2016 to November 2018. Transthoracic echocardiography (TTE) was performed within 1 year of right heart catheterization (RHC). Echo-Pac software from GE Healthcare® was used to perform echocardiographic analysis. PAC was calculated dividing right ventricular stroke volume by pulmonary arterial pulse (systolic – diastolic) pressure, measured by RHC.

Results

Of the 105 enrolled patients, 43 were had HFpEF-PH. Among these, 72% were female and mean age was 68.9 ± 11.2 years. Median time between TTE and RHC was 68 (IQR 34 – 191) days. Most patients were in NYHA class II (60.5%) and class III (34.9%). Fifty eight percent of the patients had history of paroxysmal or permanent atrial fibrillation. This population presented borderline parameters of right ventricle (RV) systolic dysfunction: fractional area change (FAC) 35.3 ± 9.2%, tricuspid annular plane systolic excursion (TAPSE) 18.3 ± 5.1 mm, tricuspid S’ wave 10.4 ± 2.9 and RV global longitudinal strain -15.5 ± 4.0. Regarding invasive assessment, this population presented mean pulmonary artery pressures of 38.8 ± 13.9 mmHg, pulmonary artery wedge pressure of 21.6 ± 6.4 mmHg, pulmonary vascular resistance of 3.9 ± 2.7 Wood and median PAC of 0.13 (IQR 0.09 – 0.19) ml/mmHg. The TAPSE / Pulmonary arterial systolic pressure (PASP) ratio and the Right ventricular outflow track velocity time integral (RVOT VTI) / PASP ratio were the parameters that best correlated with PAC (r = 0.69, p = 0.002 for both parameters) (table 1). These parameters were obtainable in the majority of patients (31/43). Blant-Altman analysis revealed good agreement between these measures and PAC with a mean difference of - 0.17 (CI -0.21 - -0.13) for RVOT VTI / PASP ratio and -0.23 (CI -0.28 - -0.18) for TAPSE /PASP ratio.

Conclusion

In a HFpEF – PH population, TAPSE / PASP and RVOT VTI / PASP are easily obtainable in most patients and significantly correlate with PAC.

Abstract P1289 Figure.

P1505 Echocardiographic assessment of different pulmonary hypertension groups

Introduction

Noninvasive echocardiography evaluation of the right ventricle (RV) has been shown to have prognostic value in patients with pulmonary hypertension (PH). Different etiology groups might have different echocardiographic phenotypes. In this study, we aimed to study echocardiographic characterization of the different PH groups and its ability to predict pulmonary vascular disease severity.

Methods

We collected echocardiographic and right heart catheterization (RHC) data from 97 (75% female, age 65 ± 15 years) consecutive patients referred to an expert tertiary care referral PH centre from 12/2016 to 11/2018. Echocardiographic analysis was performed using Echo-Pac software from GE Healthcare®. Group 3 and 5 were not included in the group comparison analysis due to few patients included.

Results

Group 2 PH was the most frequent etiology of PH (35), followed by group 1 (26), group 4 (18), group 5 (3) and group 3 (2). The echocardiographic evaluation of this population as a whole showed borderline parameters of RV dysfunction (tricuspid annular plane systolic excursion (TAPSE) 18 ± 4 mm, fractional area change (FAC) 33 ± 10% and S’ tricuspid wave 10 ± 3 cm/sec). Mean RV global strain was -15 ± 5 and RV free wall strain was -17 ± 7.

PH group 1 had a significantly lower FAC (26 ± 4%, p = 0.0025), higher eccentricity index (IE) (1.5 ± 0.1, p = 0.01), and more frequently RV outflow tract (RVOT) notching than other groups (62%, p = 0.012). Group 4 presented an intermedium echocardiographic phenotype between group 1 and 2, and showed more abnormal strain values than the other groups. Group 2 had fewer patients in sinus rhythm (atrial fibrillation in 34% of patients, p = 0.02), presented a thicker interventricular septum (11.3 ± 1.8, p = 0.014), a higher FAC (35 ± 3%, p = 0.0025), higher E mitral wave velocity (72 ± 6 cm/s, p < 0.001) and E/E’ ratio (12.7 ± 10.2, p = 0.006), and larger left (45 ± 3 cm3/m3, p < 0.01) and right atria (25 ± 2 cm2, p = 0.03).

PH groups 1 and 4 had higher Pulmonary Vascular Resistance (PVR) and Pulmonary Mean Arterial Pressure (PMAP) values than group 2, which significantly correlated with echocardiographic RV function parameters as TAPSE, FAC, RV global strain and IE. In PH group 2, eccentricity index was the only predictor of PVR (β=4.1, p = 0.018). In this population, a left atria volume < 32.7 cm3/m2 (OR 4.25, CI 1.71 - 10.55) and a E/e’ ratio < 12 (OR 4.72, CI 2.05 - 10.87) predicted PECP < 15 mmHg. RV global strain > -17.1 predicted PVR > 3 wood (OR 3.46, CI 1.50 - 8.02) and PMAP > 20 mmHg (OR 4.92, CI 1.67 - 14.51). TAPSE < 18 mm predicted PVR > 3 wood (OR 7.41, CI 2.99 - 18.36, AUC 0.72).

Conclusion

Different PH groups present mild echocardiographic differences between them. PH group 1 presented with more echocardiographic signs of RV disfunction, and PH group 2 had higher FAC, E/E’ and larger right and left atria. RV function parameters predicted PVR in PH groups 1 and 4, and EI was the only predictor of PVR in PH group 2.

Abstract P1505 Figure.

Pharmacologic interventions for fatigue in cancer and transplantation: a meta-analysis

Background

Our objective was to determine whether, compared with control interventions, pharmacologic interventions reduce the severity of fatigue in patients with cancer or recipients of hematopoietic stem-cell transplantation (hsct).

Methods

For a systematic review, we searched medline, embase, the Cochrane Central Register of Controlled Trials, cinahl, and Psychinfo for randomized trials of systemic pharmacologic interventions for the management of fatigue in patients with cancer or recipients of hsct. Two authors independently identified studies and abstracted data. Methodologic quality was assessed using the Cochrane Risk of Bias tool. The primary outcome was fatigue severity measured using various fatigue scales. Data were synthesized using random-effects models.

Results

In the 117 included trials (19,819 patients), the pharmacologic agents used were erythropoietins (n = 31), stimulants (n = 19), l-carnitine (n = 6), corticosteroids (n = 5), antidepressants (n = 5), appetite stimulants (n = 3), and other agents (n = 48). Fatigue was significantly reduced with erythropoietin [standardized mean difference (smd): -0.52; 95% confidence interval (ci): -0.89 to -0.14] and with methylphenidate (smd: -0.36; 95% ci: -0.56 to -0.15); modafinil (or armodafinil) and corticosteroids were not effective.

Conclusions

Erythropoietin and methylphenidate significantly reduced fatigue severity in patients with cancer and in recipients of hsct. Concerns about the safety of those agents might limit their usefulness. Future research should identify effective interventions for fatigue that have minimal adverse effects.

Small structural changes of the imidazopyridine diacylglycerol acyltransferase 2 (DGAT2) inhibitors produce an improved safety profile

Small molecule DGAT2 inhibitors have shown promise for the treatment of metabolic diseases in preclinical models. Herein, we report the first toxicological evaluation of imidazopyridine-based DGAT2 inhibitors and show that the arteriopathy associated with imidazopyridine 1 can be mitigated with small structural modifications, and is thus not mechanism related.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Histone deacetylase (HDAC) encoding gene expression in pancreatic cancer cell lines and cell sensitivity to HDAC inhibitors

PURPOSE

Multiple biochemical and molecular alterations occur in pancreatic cancer cells. In the present study, attempts were made for the first time, to explore the level of expression of members of histone deacetylase encoding genes (HDACs) in four pancreatic tumor cell lines: Panc-1, BxPC-3, SOJ-6 and MiaPaCa-2; and two non-related tumor cells: Jurkat and HeLa. Furthermore, we examined the possible relationship between the levels of HDACs expression and the sensitivity/resistance to HDAC inhibitors (TSA, Nicotinamide and Sirtinol).

RESULTS

We have found that although a slight variation in the profiles of gene expression among cell lines could be evidenced, HDACs protein synthesis seem to be similar. Furthermore, the cells were equally sensitive to inhibition by Sirtinol whereas some variation in the IC(50) could be seen in the case of TSA. We also demonstrate that the drugs had the capacity to induce the death of cells by apoptosis.

METHODS

We have used four human pancreatic tumor cell lines and two-non related tumor cells, to evaluate the expression of HDAC encoding genes by RT-PCR and Western blot analysis. We also measured the effect of certain HDAC inhibitors (HDIs) on cell growth, cell cycle alteration, membrane phosphatidyl-serine exposure, DNA fragmentation and mitochondrial membrane potential loss.

CONCLUSIONS

Taken together, our data support the notion that the level of cell sensitivity to the HDIs might be related to the level of expression of genes such as those encoding proteins playing a role in cell cycle checkpoints control but not HDAC per se.

[Visceral leishmaniasis and HIV infection in the HAART era]

Visceral Leishmaniasis is an endemic infection in Portugal, as well as in other Mediterranean basin countries, where it has become a frequent complication of HIV infection. There are several studies published about Leishmania/HIV co-infection, however some particularities of its epidemiology, pathogenesis and especially of its treatment and prophylaxis remain unclear and undefined. The authors review some aspects of this co-infection, particularly epidemiology, clinical classic manifestations and laboratory features, diagnosis, treatment, prophylaxis and prevention and report the casuistic of the Infectious Diseases Department of the University Hospital of Coimbra during the last ten years (1996-2006) in the HAART (<<highly active antiretroviral therapy>>) era. Visceral Leishmaniasis behaves as an opportunistic infection in HIV-infected patients and should be considered as an AIDS-defining disease. Nowadays and according to World Health Organization, VL is the second most important protozoan disease and one of the most neglected; therefore the establishment of treatment and prophylaxis guidelines is urgent.

Quality of life (QoL) improvements in 1,464 patients (pts) with metastatic breast cancer (MBC) receiving capecitabine (X) in Brazil: Updated results from a large pt cohort, including analysis as a function of pts’ ECOG PS

8599

Background: The oral fluoropyrimidine capecitabine is highly active and well tolerated as single-agent therapy and extends survival when added to docetaxel in pretreated MBC. QoL data would enhance understanding of X’s pt benefits. Methods: QoL was evaluated in women with anthracycline ± taxane-pretreated MBC while receiving X (baseline, before cycle 1, at weeks 7 and 13, and at treatment end) using EORTC QLQ C-30 (v3.0) and BR-23 questionnaires. We used linear models with repeated measures (generalized estimating questions technique) and SAS (v8.2) to determine improvement, stabilization or worsening of QoL scores from week 7 onwards. Each questionnaire item was analyzed as a function of pts’ ECOG status before first cycle and the evaluation periods. Results: Baseline characteristics of the 1,464 evaluable pts were: median age 54 years (range 22–92); 42% had ECOG 0. As expected, pts with worse initial PS (ECOG ≥2) had lower mean scores during treatment. Regardless of baseline ECOG score, X therapy was associated with significant (p<0.0001 unless stated) improvements in pts’ perception of: role functioning (p=0.001), pain, nausea/vomiting, fatigue, constipation, emotional functioning, and global health status. Capecitabine was also associated with significant improvements in pts’ perception of systemic therapy side effects (p<0.0001), breast symptoms (p<0.0001), arm symptoms (p=0.0047), hair loss (p<0.0001), and future perspective (p<0.0001). Conclusions: Pts receiving X had substantial improvements in almost all functional and symptomatic QoL domains. These findings highlight the importance of considering QoL and other measurable benefits of oral treatments alongside well-established measures of clinical evaluation in pts with metastatic disease. The QoL benefits, together with other proven clinical outcomes, suggest that early use of X in MBC would be of benefit to pts.

No significant financial relationships to disclose.

Evaluation of quality of life (QoL) in 1,210 patients (pts) with metastatic colorectal cancer (MCRC) treated with capecitabine (X) in Brazil: Udated results from a large pt cohort with analysis as a function of pts’ ECOG PS

8586

Background: The oral fluoropyrimidine X has superior efficacy and improved safety vs. 5-FU/LV in MCRC and early-stage colon cancer. Consequently, X is replacing 5-FU/LV as the backbone of MCRC therapy and is moving into the adjuvant setting. The QoL benefits of oral agents like X over traditional i.v. drugs are becoming more important in MCRC. Methods: Pts with MCRC who received standard oral X (1,250 mg/m2 twice daily on days 1–14, every 3 weeks) until progressive disease or unacceptable toxicity completed EORTC QLQ C-30 (v3.0) and CR-38 questionnaires at baseline, before cycle 1, at weeks 7 and 13, and at end of treatment. The proportion of pts with improvement, stabilization or worsening of QoL scores from week 7 was analyzed using linear models with repeated measures (generalized estimating questions technique) and SAS (v8.2). Each questionnaire item was analyzed as a function of pts’ ECOG status before first cycle and the evaluation periods. Results: Here we report QoL findings in 1210 pts (male/female, 51%/49%); median age 60 years (range 20–91); 53% of males and 57% of females had ECOG 0 at baseline. Almost half of the pts completed QoL questionnaires through to the end of treatment. Around 42% of pts who presented ECOG ≥1 had ECOG 0 at the end of treatment. Regardless of the baseline ECOG score, pts had significant improvements (p<0.0001 unless stated) in pain (p<0.0002), stoma-related problems (p=0.0003), defecation problems (p=0.0112), appetite loss (p=0.001), weight loss, insomnia (p=0.0074), constipation, body image (p=0.0142), emotional functioning, social functioning (p=0.0170), financial problems (p=0.0407), future perspective, and global health status (p=0.0003). Conclusions: X was associated with improved QoL, with significant benefits observed in most functional/symptomatic QoL domains. The efficacy, safety and convenience benefits of X as reported previously appear to have a direct impact on QoL. These data support its increasing use in the first-line and adjuvant settings.

No significant financial relationships to disclose.

Transgenic tobacco plants expressing the potato virus X open reading frame 3 gene develop specific resistance and necrotic ring symptoms after infection with the homologous virus

Tobacco plants were transformed with the open reading frame 3 gene from Potato virus X (PVX) coding for the p12 protein. Although the transgenic plants exhibited a normal morphological aspect, microscopic examination revealed extensive alterations in leaf tissue structure. After being challenged with PVX, the transgenic plants showed resistance to PVX infection and formation of specific leaf symptoms consisting of concentric rings encircled by necrotic borders. These novel symptoms were accompanied by biochemical changes normally associated with the hypersensitive response (HR) and were absent in noninfected transgenic plants or in PVX-infected nontransgenic plants. No equivalent virus resistance was observed after inoculation with Tobacco mosaic virus or Potato virus Y, suggesting the presence of a specific resistance mechanism. Despite development of HR-like symptoms, systemic acquired resistance was not induced in PVX-infected p12 transgenic plants. No evidence of an RNA-mediated resistance mechanism was found.

Transesophageal echocardiography in the assessment of patients presenting with ischemic cerebral events without previous evidence of a cardiac source of emboli

Transesophageal echocardiography (TEE) is accepted as a valuable tool in the evaluation of ischemic stroke patients, particularly in the young and in cases of unknown cause. However, the real clinical impact of additional TEE data remains to be defined.

PURPOSE

The aim of this study was to present our experience with TEE in ischemic stroke patients without previous evidence of a cardiac source of emboli.

METHODS

From March 1991 to June 2000 we studied 172 patients (80 males, 92 females, mean age 43 +/- 12 years presenting with a transient ischemic attack or a recent cerebral infarction who had no previous evidence by clinical assessment, electrocardiogram and transthoracic echocardiography of a cardiac of emboli source. The population was divided into two groups: Group A--age < or = 45 years, n = 101 (43 males, 58 females, mean age 34 +/- 7 years) and Group B--age > 45 years, n = 71 (36 males, 35 females, mean age 54 +/- 7 years). Information was gathered from clinical records. In every case TEE included Doppler color flow imaging and multiple contrast injections (agitated saline) with and without Valsalva maneuver.

RESULTS

A potential cardiac of emboli source was found in 29% of the patients, with a higher prevalence in the older group (group A--25%, Group B--35%, ns). Atrial septal abnormalities accounted for most of the detected findings (23 patent foramen ovale, 17 atrial septal aneurysms and two atrial septal defects, representing altogether 71% of the findings). The other detected anomalies were distributed as follows: aortic plaques--six, mitral valve prolapse--five vegetations--four, thrombus in left atrial appendage--two. Only six patients (3.5%) had abnormalities which in themselves determined a specific approach, which were found mostly in the older group (Group A--two vegetations; Group B--two vegetations, two thrombi).

CONCLUSIONS

TEE identified additional findings with possible embolic potential in a considerable number of cases, the majority of which were of a debatable cause-effect relation. A higher diagnostic yield and clinical relevance was found in older patients, which argues against age being used as a selective criterion for it. Our experience suggests that routine TEE in this setting is of questionable value and has little impact on clinical management, for which reason TEE referral should be decided on an individual patient basis.

Patterns of plasma human immunodeficiency virus type 1 RNA response to highly active antiretroviral therapy in infected children

This study examined the rate of decline in plasma human immunodeficiency virus type 1 (HIV-1) RNA levels to <400 and <50 copies/mL in children receiving highly active antiretroviral therapy (HAART) consisting of efavirenz, nelfinavir, and 1 or 2 nucleoside reverse-transcriptase inhibitors. Children receiving HAART achieved a plasma HIV-1 RNA level <400 copies/mL by a median of 4 weeks after initiation of therapy and a decline to <50 copies/mL by 20 weeks. Baseline plasma HIV-1 RNA levels affected the likelihood of achieving potent and sustained virus suppression, and children whose CD4 lymphocyte counts increased >70 cells/microL by 20 weeks on therapy were more likely to achieve durable virological and immunological benefit. These data provide time frames for virus suppression after the initiation of HAART that should be useful in evaluating the potential efficacy and durability of response of newly instituted combination antiretroviral therapy in HIV-1-infected children.

Prospective, concurrent comparison of the Cobe Spectra and Haemonetics MCS-3P cell separators for leukapheresis after high-dose filgrastim in patients with hematologic malignancies

A prospective study was undertaken to compare the mononuclear cell, CD34+ cell, and CFU-GM yields of the Haemonetics MCS-3P and the Cobe Spectra cell separators in ten patients (nine multiple myeloma and one non-Hodgkin lymphoma) on two consecutive days after mobilization with high-dose filgrastim (12-16 micrograms/k) for 4 days. All patients were harvested once on each machine, five starting on each machine. The target duration of the procedure on the Spectra was 160 minutes, and the target blood volume processed on the MCS-3P was 60-70 ml/kg body weight. Both machines were operating on the 1995 software versions supplied by the respective manufacturers. The time taken for the procedure was significantly longer with the Haemonetics machine. The volumes of blood processed and the product collected were significantly higher with the Spectra, as were the absolute mononuclear and CD34+ cell yields, and yields per unit time. Mononuclear and CD34+ cell yields per unit volume of blood processed were comparable for both machines. The differences in CFU-GM yields were not significant, largely because of wide interpatient variations. The extent of platelet depletion as a result of the procedure was greater with the Spectra because of the higher blood volume being processed. We conclude that the Cobe Spectra is a significantly faster machine than the Haemonetics MCS-3P; and consequently, its use is associated with higher mononuclear and CD34+ cell yields.

[Isolated infective endocarditis of pulmonary valve in patient with interventricular septal defect]

A case of isolated infective endocarditis of the pulmonary valve in a patient with known subpulmonary interventricular septal defect that had, as major complication pulmonary septic embolization, was reported by the authors. The disease followed an insidious course, diagnosed by the presence of vegetations in the echocardiogram, some of them larger than 1 cm. They were found in the right ventricular infundibulum and in the pulmonary valve leaflets. The isolation of Estreptococcus viridans in blood cultures has confirmed the diagnosis. In spite of appropriate antimicrobial therapy, according to the antibiogram data (with Ampicillin and Gentamicin), fever lasted for more than three weeks. This event suggested medical treatment failure and the possibility of surgery was considered. However, the endocarditis eventually healed with medical therapy alone, and this unusual course with prolonged fever was presumed to be caused by lung metastatic infection secondary to septic embolization. This complication is relatively common, but lung involvement is usually a subclinical event, not responsible for such persistent fever, as happened in the case now reported. We emphasize the rarity of this case, the unusual clinical course and the discussion concerning the therapeutic options.

Comparison of marrow and blood cell yields from the same donors in a double-blind, randomized study of allogeneic marrow vs blood stem cell transplantation

Forty healthy adult donors underwent marrow (BM) as well as peripheral blood (PBSC) stem cell collections for their HLA-identical adult siblings with hematologic malignancies. BM was harvested on day 1 (target 3 x 108 nucleated cells/kg, 10 microg/kg lenograstim (glycosylated G-CSF) administered on days 2-6, and a single leukapheresis performed on day 6. The blood volume processed was the higher of 200% donor blood volume or 10 liters. The total nucleated cell (TNC) yields from PBSC were 1.1- to 4.3-fold higher than BM (median 7.0 vs 3.1 x 10(8)/kg, P < 0.0001). Although BM contained a higher proportion of CD34+cells (1.3% vs 0.7%, P < 0. 0001) and a comparable proportion of CD3+ cells (median 29% vs 26%, P = 0.4), the absolute numbers of CD34+ and CD3+ cells and their subsets were several times higher in PBSC. There was a poor correlation between BM and PBSC CD34 and TNC numbers, but a significant correlation between BM and PBSC CD3 numbers. Only five of 40 BM harvests contained >/=2 x 10(6) CD34+ cells/kg compared with 35 of 40 PBSC harvests (P < 0.0001). We conclude that the numbers of progenitor and immunocompetent cells in PBSC are several times higher than in BM. It is possible to collect adequate numbers of progenitor cells from blood after lenograstim stimulation more frequently than from marrow, and donors yielding low quantities of progenitor cells from BM usually deliver better quantities from PBSC. Bone Marrow Transplantation (2000) 25, 501-505.

Cytomegalovirus (CMV) DNA load is an independent predictor of CMV disease and survival in advanced AIDS

The impact of cytomegalovirus (CMV) on human immunodeficiency virus type 1 (HIV-1) disease progression has been controversial. In this study, we sought to determine if CMV viral load is independent of HIV-1 viral load in predicting CMV disease and survival. Our findings indicate that in patients with advanced AIDS, CMV DNA load is an independent marker of CMV disease and survival and is more predictive than HIV-1 RNA load. Moreover, patients who respond to preemptive therapy with oral ganciclovir, with resulting undetectable levels of CMV DNA, in their plasma, have a significantly lower risk of developing CMV disease and higher rates of survival, despite stable or increasing HIV-1 RNA loads. These data provide support for CMV as an independent risk factor for mortality in persons with advanced AIDS and further suggest that effective preemptive therapy for CMV can improve patient survival rates.

[Left ventricular pseudoaneurysm: a rare complication of acute myocardial infarction diagnosed by echocardiography]

Postmyocardial infarction left ventricular pseudoaneurysm resulting from free wall rupture is a very rare finding. Its recognition during life is even rarer. Definitive preoperative diagnosis is difficult, implying, in a great number of cases, the use of multiple imaging modalities. A case of a left ventricular pseudoaneurysm as a mechanical complication of acute myocardial infarction, which was diagnosed by transthoracic echocardiography, is reported. The authors emphasize its rarity, the diagnostic difficulties involved and the contribution of echocardiography to the characterization of that lesion, allowing a definitive diagnosis prior surgery in this case.

Transgenic plants expressing potato virus X ORF2 protein (p24) are resistant to tobacco mosaic virus and Ob tobamoviruses

The p24 protein, one of the three proteins implicated in local movement of potato virus X (PVX), was expressed in transgenic tobacco plants (Nicotiana tabacum Xanthi D8 NN). Plants with the highest level of p24 accumulation exhibited a stunted and slightly chlorotic phenotype. These transgenic plants facilitate the cell-to-cell movement of a mutant of PVX that contained a frameshift mutation in p24. Upon inoculation with tobacco mosaic virus (TMV), the size of necrotic local lesions was significantly smaller in p24+ plants than in nontransgenic, control plants. Systemic resistance to tobamoviruses was also evidenced after inoculation of p24+ plants with Ob, a virus that evades the hypersensitive response provided by the N gene. In the latter case, no systemic symptoms were observed, and virus accumulation remained low or undetectable by Western immunoblot analysis and back-inoculation assays. In contrast, no differences were observed in virus accumulation after inoculation with PVX, although more severe symptoms were evident on p24-expressing plants than on control plants. Similarly, infection assays conducted with potato virus Y showed no differences between control and transgenic plants. On the other hand, a considerable delay in virus accumulation and symptom development was observed when transgenic tobacco plants containing the movement protein (MP) of TMV were inoculated with PVX. Finally, a movement defective mutant of TMV was inoculated on p24+ plants or in mixed infections with PVX on nontransgenic plants. Both types of assays failed to produce TMV infections, implying that TMV MP is not interchangeable with the PVX MPs.

[The echocardiographic diagnosis of a rare complication of an aneurysm of the sinus of Valsalva]

We report the case of a patient with complete heart block caused by extension of a congenital aneurysm of the sinus of Valsalva into the upper interventricular septum, which was diagnosed by transthoracic and transesophageal echocardiography. We emphasize the rarity of this pathology and the value of transesophageal echocardiography in its assessment, providing a complete anatomicofunctional characterization and allowing surgical repair without previous cardiac catheterization.

High-dose hydroxyurea and G-CSF to collect Philadelphia-negative cells in chronic myeloid leukemia: preliminary results

Five patients with Ph+ chronic myeloid leukemia and no detectable diploid cells in the marrow received 6 g hydroxyurea twice daily for 7 days followed by G-CSF to harvest Ph-cells 1-84 months after diagnosis. Three were in first chronic phase, and two in accelerated phase. One stopped hydroxyurea after 4 doses due to intractable vomiting and was not apheresed, while two stopped hydroxyurea after 9 and 11 doses because of mucositis and skin rash. Two tolerated all doses; one with no significant side effects, and one with mucositis and painful plantar rash. The nadir leukocyte, neutrophil, and platelet counts were 0.4-0.8, 0-0.1, and 2-19 x 10(9)/L respectively. Apheresis was commenced when the leukocytes were 1.2-3.8 x 10(9)/L 9-10 days after starting G-CSF, and 6 aphereses were performed. Four collections were 100% Ph+, and two 22% and 90% Ph-. The total nucleated cell, CD34+/CD34-subset, CD34+/CD33+ subset, and CFU-GM yields per kg per collection were 0.48-2.38 (median 1.18) x 10(8), 0-0.48 (median 0.012) x 10(6), 0.028-10.19 (median 0.92) x 10(6), and 0.29-41.81 (median 21.78) x 10(4) respectively. We conclude that hydroxyurea in the dose we used is poorly tolerated, and is associated with significant adverse effects including severe myelosuppression. It is possible to harvest diploid cells during recovery, but achievement of Ph-negativity appears to be erratic and cell yields are poor.

Comparison of Cobe Spectra and Haemonetics MCS-3P cell separators for peripheral blood stem cell harvesting

A prospective study was undertaken to compare the total nucleated cell (TNC), mononuclear cell (MNC), CD34+ cell, and CFU-GM yields of two different cell separators. A Haemonetics MCS-3P and a Cobe Spectra machine were used to leukapherese 10 patients with malignant diseases on 4 consecutive days after mobilization with G-CSF. All patients were harvested twice on each machine for a fixed period of time. The blood volume processed (10.47 vs 3.79 l, P < 0.001), MNC yield (2.66 vs 0.90 x 10(8)/kg; P < 0.001), MNC yield rate (1.66 vs 0.55 x 10(6)/kg/min; P < 0.001), MNC purity (81 vs 42%; P < 0.001), CFU-GM yield (18.1 vs 5.5 x 10(4)/kg; P = 0.001), and CFU-GM yield rate (11.27 vs 3.42 x 10(2)/kg/min; P = 0.001) were significantly higher with the Spectra. The CD34+ cell yields and yield rates were comparable. Although CFU-GM and MNC yields per unit blood volume processed were comparable for both machines, there was a trend for higher CD34+ yields per unit volume processed with MCS-3P. We conclude that Spectra is faster than MCS-3P with more blood processed per unit time resulting in higher cell yields, but yields per unit volume processed are comparable for both machines. The choice of machine for a given patient depends upon convenience, venous access and the time available.

Dipyridamole inhibits reversion by thymidine of methotrexate effect and increases drug uptake in Sarcoma 180 cells

The combined effect of methotrexate (MTX) with dipyridamole, an inhibitor of nucleoside transport, was studied in ascitic Sarcoma 180 cells. It was determined that 10 microM MTX inhibits by greater than 90% deoxy[3H]uridine incorporation into DNA and that this MTX concentration inhibits DNA synthesis as revealed by deoxy[3H]cytidine but not [3H]thymidine incorporation into DNA. Exogenous thymidine (greater than or equal to 1 microM) in the cell culture medium enhances DNA synthesis in nontreated cells and fully restores it in MTX-treated cells, whereas hypoxanthine has no appreciable effect on DNA synthesis. Dipyridamole inhibits deoxy[3H]cytidine and [3H]thymidine uptake by these cells (IC50 = 0.2 and 3 microM, respectively) and blocks the increase in TTP pool produced by 1 microM thymidine in MTX-treated cells (23.1 +/- 4.7 pmol per 1 X 10(6) cells vs. 80.4 +/- 18.9 pmol per 1 X 10(6) cells). Dipyridamole at 10 microM enhances [3H]MTX accumulation by Sarcoma 180 cells and diminishes the efflux of the drug in previously loaded cells. It is suggested that the combination of inhibitors of the de novo pathway for pyrimidine biosynthesis, such as MTX, with inhibitors of the salvage pathway, such as dipyridamole, may increase the cytotoxic activity of MTX alone.