Splenic Abscesses in Endocarditis: A Rare Disease with High Mortality. The Experience of a Heart Institute in Brazil

INTRODUCTION

Splenic abscess secondary to endocarditis is a rare complication with high mortality. The treatment modality, splenectomy versus percutaneous drainage, and the best time, before or after valve replacement, are controversial. In the literature, there are only a few small case series about the subject. The objective of this study is to analyze the experience of a referral center in treating such condition.

METHODS

Patients with splenic abscesses due to endocarditis from 2006 to 2020 were retrospectively analyzed.

RESULTS

Thirteen patients (mean age 46 years old, 69% male) were identified. Eight patients (62%) had at least 2 comorbidities and 5 (38%) had a history of cardiac surgery. The diagnosis was incidental in 6 (46%). The mean time of abscess diagnosis after endocarditis definition was 14 days. Six patients (46%) had at least two organ dysfunctions. The median APACHE II score was 12 overall, and 24.5 in patients who died. Six patients (46%) had a valve replacement, and in two the abscess was diagnosed postoperatively. Of the other four patients, splenectomy was performed before the cardiac operation in three and at the same time in one. Splenectomy was performed immediately in 9 (69%) patients while three patients had percutaneous drainage (23%), one of which underwent splenectomy due to drainage failure. Exclusive antibiotic treatment was performed on only one patient. The median length of hospitalization was 24 days and mortality was 46%.

CONCLUSION

Splenic abscess due to endocarditis is a life-threatening condition with controversial treatment that results in a prolonged length of stay and high mortality.

OP0297 THE SLE-DAS ENABLES ACCURATE AND USER-FRIENDLY DEFINITIONS OF REMISSION AND CATEGORIES OF LUPUS DISEASE ACTIVITY: DERIVATION AND VALIDATION STUDY IN 1190 SLE PATIENTS

Background:

Treatment of systemic lupus erythematosus (SLE) is tailored according to the intensity of SLE disease activity and aims to achieve remission. Current definitions of remission and disease activity categories are mostly based on the SLE Disease Activity Index (SLEDAI), which has important limitations. The SLE Disease Activity Score (SLE-DAS) is a validated continuous disease activity score with higher accuracy in measuring SLE activity and higher sensitivity-to-change as compared to SLEDAI1. SLE-DAS is user-friendly with its online calculator.

Objectives:

To derive and validate the SLE-DAS cut-off values for defining SLE disease activity categories and SLE clinical remission state.

Methods:

Derivation study was conducted at the Padova Lupus Clinic. Validation was performed prospectively in patients from the Cochin Lupus Clinic and by post-hoc analysis of BLISS-76 (NCT00410384) trial. Gold-standard for clinical remission state was fulfillment of Definition Of Remission In SLE (DORIS). In Padova and Cochin Clinics, at time of inclusion, a senior clinician classified each patient as presenting: (i) remission, (ii) mild, or (iii) moderate/severe disease activity. Derivation of the SLE-DAS cut-offs for disease activity categories was performed using ROC curve analysis against this expert clinical classification. Performance of these SLE-DAS categories of disease activity was assessed as compared with: (i) expert classification (in Cochin cohort); (ii) British Isles Lupus Assessment Group (BILAG) index (in BLISS-76). An index-based and a Boolean definition of remission were tested applying decision trees, using CHAID (chi-square automatic interaction detection) algorithm and their performance estimated.

Results:

We included 1190 SLE patients (221 in Padova, 150 in Cochin and 819 from BLISS-76 cohorts). In the derivation cohort, best SLE-DAS cut-off values for disease activity categories were: (i) remission, SLE-DAS≤2.08; (ii) mild activity, 2.08<SLE-DAS≤7.10; (iii) moderate/severe activity, SLE-DAS>7.10. Table 1 shows the performance of these SLE-DAS cut-offs. The SLE-DAS Boolean-based definition of remission (all SLE-DAS clinical items scores = 0 and prednisone ≤5mg/day) showed sensitivity and specificity of 100% in the derivation (Padova) and validation (Cochin) clinical cohorts. The SLE-DAS index-based definition of remission (SLE-DAS ≤2.08 and prednisone ≤5mg/day) presented sensitivity =100% and specificity =97.4% in the derivation and validation clinical cohorts. The SLE-DAS definitions of remission were fully substantiated by CHAID.

Table 1.

Performance of SLE-DAS cut-offs for remission and disease activity categories compared to physician’s classification and BILAG (n =1190).

Disease activity categorySensitivity (%)Specificity (%)Accuracy (%)DerivationPadova CohortRemission(SLE-DAS≤2.08)99.397.198.6Mild Disease Activity(2.08<SLE-DAS≤7.10)74.298.995.5Moderate and Severe Disease Activity(SLE-DAS>7.10)97.496.796.8ValidationCochin CohortRemission(SLE-DAS≤2.08)99.193.998.0Mild Disease Activity(2.08<SLE-DAS≤7.10)82.699.296.7Moderate and Severe Disease Activity(SLE-DAS>7.10)100.098.698.7ValidationBLISS-76Remission and Mild Disease Activity§vs. Moderate and Severe Disease Activity§§ (SLE-DAS≤7.10 vs. >7.10)91.484.190.8

§ Remission/Mild: No BILAG B or A scores

§§ Moderate/severe: ≥1 BILAG B or A scores

Conclusion:

The SLE-DAS is an accurate and easy to use tool for defining clinical remission state and SLE disease activity categories, validated with both the expert assessment and BILAG.

References:

[1]Jesus D, et al. Derivation and validation of the SLE Disease Activity Score (SLE-DAS): a new SLE continuous measure with high sensitivity for changes in disease activity. Ann Rheum Dis 2019;78:365-71.

Acknowledgements:

The authors would like to thank GlaxoSmithKline (Uxbridge, UK) for granting access to the data from the BLISS-76 trial through the Clinical Study Data Request consortium.

Disclosure of Interests:

None declared

Oxidative stress and mitochondrial dysfunction play a role in myelodysplastic syndrome development, diagnosis, and prognosis: A pilot study

The imbalance between reactive oxygen species (ROS) production and their elimination by antioxidants leads to oxidative stress. Depending on their concentration, ROS can trigger apoptosis or stimulate cell proliferation. We hypothesized that oxidative stress and mitochondrial dysfunction may participate not only in apoptosis detected in some myelodysplastic syndrome (MDS) patients, but also in increasing proliferation in other patients. We investigated the involvement of oxidative stress and mitochondrial dysfunction in MDS pathogenesis, as well as assessed their diagnostic and prognostic values. Intracellular peroxides, superoxide, superoxide/peroxides ratio, reduced glutathione (GSH), and mitochondrial membrane potential (Δψ(mit)) levels were analyzed in bone marrow cells from 27 MDS patients and 12 controls, by flow cytometry. We observed that all bone marrow cell types from MDS patients had increased intracellular peroxide levels and decreased GSH content, compared with control cells. Moreover, oxidative stress levels were MDS subtype- and risk group-dependent. Low-risk patients had the highest ROS levels, which can be related with their high apoptosis; and intermediate-2-risk patients had high Δψ(mit) that may be associated with their proliferative potential. GSH levels were negatively correlated with transfusion dependency, and peroxide levels were positively correlated with serum ferritin level. GSH content proved to be an accurate parameter to discriminate patients from controls. Finally, patients with high ROS or low GSH levels, as well as high superoxide/peroxides ratio had lower overall survival. Our results suggest that oxidative stress and mitochondrial dysfunction are involved in MDS development, and that oxidative stress parameters may constitute novel diagnosis and/or prognosis biomarkers for MDS.

Membrane progesterone receptors in human regulatory T cells: a reality in pregnancy

OBJECTIVE

To provide evidence of the existence of membrane progesterone receptor alpha (mPRα) on regulatory T cells (Treg) in peripheral blood during pregnancy, postulating a possible explanation for the effect of progesterone on preterm birth.

DESIGN

Cross-sectional study.

SETTING

Tertiary Obstetric Department in a University Hospital.

POPULATION

Healthy pregnant women.

METHODS

Treg cells from peripheral blood samples were studied by flow cytometry using multiple monoclonal antibody expression.

MAIN OUTCOME MEASURES

Evaluate the number and percentage of CD4(+) CD25(high) CD127(low) , the number and percentage of Treg cells among the total CD4(+) T cells, and the percentage and mean fluorescence intensity (MFI) of mPRα in that population, using several gating strategies.

RESULTS

43 peripheral blood samples were collected from healthy women during pregnancy, whose median gestational age was 28.7 ± 7.1 (16-40) weeks. The percentage of CD4(+) in the total lymphocytes was 43% (32-51) and the percentage of CD4(+) CD25(high) CD127(low) was 4.8% (1.6-5.9), with only 45% (16-72) of those cells expressing the intracellular marker FoxP3 (Treg cell pool). We confirmed the existence of mPRα in that specific population because 8.0% (2.02-33) of the Treg cells were marked with the specific monoclonal antibody, with an mPRα(+) MFI of 719 (590-1471).

CONCLUSIONS

This research shows that Treg cells express mPRα during pregnancy, which might play an important role in immune modulation by progesterone.

Monoterpenic aldehydes as potential anti-Leishmania agents: activity of Cymbopogon citratus and citral on L. infantum, L. tropica and L. major

In order to contribute for the search of new drugs for leishmaniasis, we study the susceptibility of Leishmania infantum, Leishmania tropica and Leishmania major to Cymbopogon citratus essential oil and major compounds, mrycene and citral. C. citratus and citral were the most active inhibiting L. infantum, L. tropica and L. major growth at IC(50) concentrations ranging from 25 to 52 μg/ml and from 34 to 42 μg/ml, respectively. L. infantum promastigotes exposed to essential oil and citral underwent considerable ultrastructural alterations, namely mitochondrial and kinetoplast swelling, autophagosomal structures, disruption of nuclear membrane and nuclear chromatin condensation. C. citratus essential oil and citral promoted the leishmanicidal effect by triggering a programmed cell death. In fact, the leishmanicidal activity was mediated via apoptosis as evidenced by externalization of phosphatidylserine, loss of mitochondrial membrane potential, and cell-cycle arrest at the G(0)/G(1) phase. Taken together, ours findings lead us to propose that citral was responsible for anti-Leishmania activity of the C. citratus and both may represent a valuable source for therapeutic control of leishmaniasis.

Aging and asthma - changes in CD45RA, CD29 and CD95 T cells subsets

BACKGROUND

Aging is associated with thymus involution leading to a reduction in naive T cells and to an accumulation of effector-memory cells. Apoptosis is a key mechanism to clear the immune system from activated and harmful cells. In asthma the stimulation of T cells by environmental antigens can decrease naive cells and sustain activated cells. The aim of this work was to evaluate the imbalance between CD45RA and CD29 cells during the aging process and their changes in elderly asthma and to evaluate how elderly and chronic diseases like asthma can affect susceptibility to apoptosis.

METHODS

Elderly and young adult healthy volunteers and elderly asthmatic patients were submitted to skin prick tests, immunoglobulin determination and flow cytometry analyses of CD3, CD4, CD8, CD45RA, CD29, and CD95.

RESULTS

Serum IgE was increased in allergic patients (p=0.0001). Asthmatics presented an increase in CD4 cells (p<0.05). CD45RA was significantly decreased in elderly individuals (p<0.05) and this decrease was higher in asthmatics (p<0.05). CD29 was increased in elderly healthy individuals compared to the control young group (p=0.0001). A negative correlation between CD29 and CD45RA (p<0.05) was observed. CD95 lymphocytes increased in elderly (p=0.0001) and a positive correlation between age and CD95 (p<0.05) was found. Asthmatic patients showed significant decreases in CD95 (p=0. 0001).

CONCLUSIONS

Naive cells are key cells in the defence against infections and their decrease in the elderly and in asthma is a bad prognosis factor. The reduction of apoptosis markers can promote the persistence of activated cells involved in chronic conditions.

Regulatory T cells in elderly patients with asthma

BACKGROUND

Airway walls in asthma present an accumulation of activated cells that determine bronchial structural changes and disease progression and severity. During the aging process, the immunoinflammatory response changes as a consequence of chronic antigenic stress.

OBJECTIVE

To evaluate T-cell subsets with regulatory functions associated with asthma in elderly patients

METHODS

A group of 153 individuals (95 with controlled asthma and 58 healthy controls) aged over 65 years was studied. Blood samples were collected for flow cytometry analyses of CD3, CD4, CD8, CD56, CD56CD8, CD3CD4CD25, CD3CD4CD25CD127, CD4HLA-DR and TCRgamma delta.

RESULTS

Asthmatic patients showed a statistically significant increase in CD4+ T cells. CD3CD4CD25high and CD3CD4CD25highCD127high cells were also significantly increased in asthmatic patients, while CD3CD4CD25highCD127low cells had similar values in asthmatics and in the control group. CD4HLA-DR cells were within the normal range in both groups. A positive correlation between CD3CD4CD25highCD127low and CD4HLA-DR was observed and gamma delta T cells were significantly decreased in the asthmatic patients compared to the controls.

CONCLUSIONS

Since T cells with regulatory functions were within normal ranges or reduced in asthmatic patients compared to healthy controls, at least in basal conditions, it can be speculated that they probably play a limited role in chronic asthma in elderly patients.These data suggest an absence of a modulatory effect on the inflammatory response that characterizes asthma and allergy, which in turn would facilitate the persistence of disease in this population. Underlying inflammatory processes that are involved in chronic diseases associated with aging could provide an additional explanation for the attenuated differences observed between asthmatic and nonasthmatic individuals.

The evaluation of neopterin and antioxidants in long lasting asthma

Asthma is a condition characterised by a chronic immunoinflammatory response to different triggers. Neopterin (NPT) is synthesised by human macrophages upon stimulation with interferon-gamma and is also capable of enhancing the oxidative potential of reactive oxygen species. NPT is useful for the monitoring of cell-mediated (Th1-type) immune activation. This study analysed the behaviour of NPT in long lasting asthma, considering its role as a marker of Th1 environment. Allergic parameters (skin prick tests, Immunoglobin E (IgE), and eosinophil count) and NPT were evaluated in an asthmatic group and in a control group. We also analysed the C Reactive Protein (CRP) concentration, Total Antioxidant Status (TAS) and Superoxide Dismutase Enzyme (SOD) in both groups. A group of individuals aged over 65 years old was selected. It included 64 asthmatic patients (72+/-5 years) and 41 healthy individuals (79+/-7 years). Blood cell counts showed statistically different median values of eosinophils (5.42+/-4.7 vs 2.8+/-2.8;p<.04), IgE (493.2+/-549.8 vs 85.3+/-194.UI/ml; p=.000) and NPT was non-statistically decreased (2.4+/-2.8 vs 4.0+/-4.7 ng/ml) in allergic asthmatic patients when compared with non-allergic asthmatic patients. Both allergic and non-allergic asthmatic patients presented a statistically significant decreased expression of TAS (0.84+/-0.14/0.86+/-0.11 vs 0.91+/-0.10 mM) and SOD (584.8+/-108.7/595.6+/-235.9 vs 822.9+/-179.5) when compared with normal control subjects. Our results suggest macrophage involvement in asthma pathogenesis. The deficit in antioxidant defence impacts negatively on this disease. The increase of NPT values in non-allergic asthma consolidates these affirmations and mapping this parameter should be part of the work of an analytical study panel as it may lead to allergic asthma being distinguished from non- allergic asthma.

Apoptosis and asthma in the elderly

BACKGROUND

Asthma is a chronic inflammatory disorder of the airways. The persistence of airway inflammation depends on a decrease in apoptosis of T lymphocytes and eosinophils and survival of these activated cells. T lymphocytes expressing gamma delta receptors can be identified in human lungs and play an important role in immune defence against pathogens and in the regulation of chronic inflammation. Aging is associated with evidence of some immune dysregulation.

OBJECTIVE

The aim of this study was to analyze the apoptosis receptors of T lymphocytes in long-lasting asthma, to establish their correlation with activation markers such as CD25+ and human leukocyte antigen (HLA)-DR+, and to analyze the gama delta T cell expression in this disease.

METHODS

A group of 64 individuals (group A) who had had asthma for more than 30 years (mean age [+/-SD] 72 +/- 5 years) and 61 healthy individuals acting as controls--group B with 41 individuals (mean age 79 +/- 7 years) and group C with 20 individuals (mean age 38 +/- 12 years) were included in the study. All subjects underwent clinical evaluation and spirometric testing. Peripheral blood cells were stained with monoclonal antibodies anti-CD3, anti-CD4, anti-CD8, anti-CD25, anti-TCR gamma delta, anti-HLA-DR and anti-CD95. Statistical comparisons were performed between the asthmatics and the elderly control group and between the elderly control group and the adult control group.

RESULTS

The average percentage of predicted forced expiratory volume in the first second was 73.6 gamma delta 25.3. The mean values of T cell receptors for asthma group A vs elderly control group B vs adult control group C respectively, were the following: CD3, 74.9+/-7 vs. 74.8 +/- 8.8 (P=ns) vs. 76.7 +/- 4.2 (P=ns); CD4, 48.8 +/- 8.7 vs. 43.5 +/- 10.2 (P=ns) vs. 44.8 +/- 3.8 (P=ns); CD8, 23.3 +/- 7.9 vs. 25.7 +/- 10.2 (P=ns) vs. 25.6 +/- 4.5 (P=ns); CD25, 14.3 +/- 5.9 vs. 22.4 +/- 7.8 (P = .0001) vs. 5.5 +/- 2.4 (P = .0001); TCR gamma delta, 2.8 +/- 2.1 vs. 4.1 +/- 3.3 (P < .05) vs. 4.6 +/- 2.1 (P=ns); HLA-DR, 18.4 +/- 9.2 vs. 17.8 +/- 5.9 (P=ns) vs. 15.4 +/- 5.1 (P=ns) and CD95, 49.3 +/- 13.7 vs. 52.6 +/- 12.1 (P=ns) vs. 13.8 +/- 10.8 (P = .0001).

CONCLUSIONS

The immunological and inflammatory changes related to ageing may cause an increase in CD95 and CD25 T cell expression. In asthma, blood cells may express increased activation and apoptosis markers but in elderly patients taking steroids, these receptors remain within normal ranges. The number of gamma delta T cells may be lower in long-lasting asthma, and have a limited modulatory effect on allergic inflammatory reactions. The evaluation of patients with long-lasting asthma should take into account the immunological and inflammatory changes present in the elderly in order to avoid results being misinterpreted.

Elevated neopterin levels in non-allergic asthma

Neopterin is synthesized by human monocyte-derived macrophages upon stimulation with interferon-gamma (IFN-gamma). Measurement of neopterin concentration is useful to monitor cell-mediated (Th1-type) immune activation. In this study, we aimed to analyze the behaviour of neopterin in long lasting asthma considering its role as a marker of the Th1 environment and to establish the distinction between patients belonging either to the allergic or the non-allergic population, particularly in the elderly where asthma is often under diagnosed. Therefore we evaluated allergic parameters such as skin prick tests, IgE and hemogram (eosinophils count), and we compared our findings with neopterin values found in an age-matched control population. A group of individuals older than 65 was selected. It included 64 asthmatic patients (mean age 72+/-5 years) and 41 healthy individuals (mean age 79+/-7 years). In our study population, 42 patients presented positive skin tests, mainly to house dust mites. All patients were clinically stable and presented an average percentage of predicted forced expiratory volume in the first second (FEV1) of 73.6+/-25.3 and predicted median expiratory flow percentage (MEF50) of 38.8+/-26.7. Blood cell counts showed statistically different mean values of eosinophils between allergic and non-allergic controls (5.42+/-4.7% versus 2.8+/-2.8%; p<0.04). IgE values were increased in allergic asthmatic patients when compared with non-allergic asthmatic patients (493.2+/-549.8IU/ml versus 85.3+/-194.4IU/ml; p=0.000). Allergic asthmatic patients presented mean neopterin levels similar to those found in the control group (2.4+/-2.8ng/ml versus 2.1+/-1.9ng/ml). In contrast, in non-allergic asthmatic patients these values were higher when compared with the control group (4.0+/-4.7ng/ml versus 2.1+/-1.9ng/ml). Neopterin levels were lower in allergic asthmatic patients when compared with non-allergic asthmatic patients (2.4+/-2.8ng/ml versus 4.0+/-4.7ng/ml). Within asthmatic patients, those with higher neopterin values (>2.1ng/ml) presented lower mean IgE values (IgE</=336.58IU) than those with lower neopterin values (</=2.1ng/ml) who presented mean IgE values of 402.70IU. Our initial findings may lead to a better understanding of the immunoinflammatory pathways in asthma. Further studies will probably show that serum neopterin could became a useful marker for asthma classification including in elderly patients with long lasting disease.

Tremor as the first neurological manifestation of Sneddon's syndrome

We report on a 54-year-old woman with Sneddon's syndrome manifested by livedo reticularis, fetal losses, hypertension, and high antinuclear antibody titres. At the age of 42 years she developed tremor of the trunk, limbs, and head only in the standing position that interfered with walking, followed some years later by cognitive decline and a parkinsonian syndrome. T2-weighted brain magnetic resonance imaging showed high signal in cortical areas, basal ganglia, midbrain, and cerebellum.

Abnormalities in dendritic cell and macrophage accumulation in the pancreas of nonobese diabetic (NOD) mice during the early neonatal period

Dendritic cell (DC), macrophage (Mphi) and lymphocyte infiltrations have been observed in normal human perinatal pancreata, but have never been investigated so early in control mice. In type 1 diabetes-prone NOD mice, these cells are thought to infiltrate first the periphery of the islets of Langerhans around weaning before further islet infiltration and beta-cell destruction. We quantified, during the first month of life, the numbers of DC (characterized by CD11c positivity and dendritic morphology), histiocyte-like Mphi (characterized by ER-MP23 positivity) and Mphi with scavenging potential (characterized by BM8 positivity) in C57BL/6, DBA/2 and BALB/c control, and NOD and lymphocyte-deficient NODscid mouse pancreata. First, CD11c+ DC were present at low densities from birth onwards in control pancreata, while densities were higher in NOD and NODscid. Second, high numbers of BM8+ and ER-MP23+ Mphi were observed at birth in all strains investigated. After birth, particularly BM8+ cells disappeared progressively in control strains, but not in NOD and NODscid. Third, NOD mice also had more ER-MP23+ Mphi at birth compared to controls. Finally, DC and Mphi localizations were similar in all strains, i.e., mostly as dispersed cells in perivascular, periductular, peri-islet areas and interlobular septa. The most remarkable finding was that particularly BM8+ Mphi, were seen at sites of islet neogenesis and predominantly at the duct-islet interface. Our data showed that different types of APC were present in the pancreas during postnatal development in various control mouse strains and some differences were observed in NOD and NODscid mice from birth onwards.

Diabetes increases the expression of hypothalamic neuropeptides in a spontaneous model of type I diabetes, the nonobese diabetic (NOD) mouse

1. Synthesis of oxytocin (OT) and arginine-vasopressin (AVP) is increased in induced models of Type I diabetes, such as the streptozotocin model. However, these parameters have not yet been evaluated in spontaneous models, such as the nonobese diabetic mouse (NOD). Therefore, we studied in the magnocellular cells of the paraventricular nucleus (PVN) of nondiabetic and diabetic 16-week-old female NOD mice and control C57B1/6 mice, the immunocytochemistry of OT and AVP peptides and their mRNA expression, using nonisotopic in situ hybridization (ISH). 2. In nondiabetic and diabetic NOD female mice, the number of OT- and AVP-immunoreactive cells were similar to those of the controls, whereas immunoreaction intensity was significantly higher for both peptides in diabetic NOD as compared with nondiabetic NOD and control C57B1/6 mice. 3. ISH analysis showed that the number of OT mRNA-containing cells was in the same range in the three groups, whereas higher number of AVP mRNA expressing cells was found in diabetic NOD mice. However, the intensity of hybridization signal was also higher for both OT and AVP mRNA in the diabetic group as compared with nondiabetic NOD and control mice. 4. Blood chemistry demonstrated that haematrocrit, total plasma proteins, urea, sodium, and potassium were within normal limits in diabetic mice. Thus, NOD mice were neither hypernatremic nor dehydrated. 5. We suggest that upregulation of OT and AVP reflects a high-stress condition in the NOD mice. Diabetes may affect neuropeptide-producing cells of the PVN, with the increased AVP and OT playing a deleterious role on the outcome of the disease.

[Immunologic and epidemiologic characterization of non-responders/low-responders to hepatitis B vaccine]

An important reduction in morbidity and mortality due to hepatitis B was achieved with the discovery of an effective vaccine. However, 2 to 10% of healthy adults do not respond to vaccination with the production of protective levels of antibody anti-HBs (assumed as protective, concentrations of ab. anti-HBs > 10 UI/L). Therefore, the aim of the present work was to study epidemiological (sex, age, obesity, alcoholic and smoking habits, previous diseases) and immunological factors (white cell count, immunoglobulins and sub-classes of IgG, lymphocytic populations and sub-populations) in a group of 20 healthcare workers with a low response (anti-HBs < 50 UI/L) to a genetically-engineered vaccine (Engerix B). The results were compared to the ones found in an identical sample of responders (anti-HBs > 100 UI/L) from the same population. No statistically significant differences regarding the epidemiological data, differential white cell counts and immunoglobulin quantification (IgG, IgA, IgM, IgG1, IgG2, IgG3) were detected. The mean value of IgG4 (mean = 54.53 +/- 59.8 mg/dl) in non/hyporesponders was significantly higher (p = 0.038) when compared to the same result in responders (mean = 33.76 +/- 31.30 mg/dl). A statistically significant difference (p < 0.05) in the quantification of double negative lymphocytic T sub-populations was also found, the mean value being higher in the responders (mean = 6.5 +/- 4.1% versus 4.6 +/- 2.3%).

CONCLUSIONS

The effectiveness of recombinant hepatitis B vaccines is well known. However, a number of apparently healthy people are unable to achieve protective titres of anti-HBs after vaccination. As our study groups did not have a considerable number of cases, we can not establish definitive conclusions based on differences found in the quantification of IgG4 and double negative lymphocytic T sub-populations. It seems to us that an investment in future research into the eventual causes of nonprotective response and into new strategies of immunization of non/hyporesponders are appropriate. In the meantime, the occupational daily risk of exposure to infected body fluids makes adequate hepatitis B immunization of healthcare workers a priority.

A unified framework for data modeling on medical information systems

Medical Information Systems (MIS) are seen as a way of optimizing the use of existing health-care infrastructure, without resorting to new and costly hospital (re)construction. The qualitative (re)design of such an environment requires a basic understanding of patient and doctors related characteristics and capabilities. Patient care, patient education, medical education, and clinical research need to be considered to meet the basic requirements on the level of services desirable, determined on the basis of the patient's length of stay; i.e., used for modeling the significant entities of such a world. The aim is to extract conclusions for the level of services provided to the users. One's concept will capture, as well as will integrate, the basic design principles under which MIS may be set.

[Status epilepticus in the childhood. A review of seven years]

INTRODUCTION

Status epilepticus is a neurological emergency that requires early and prompt treatment.

PATIENTS AND METHODS

This retrospective study includes 32 children treated for status epilepticus at Hospital Geral de Santo António, from January 1992 to December 1998. We evaluated the clinical features, duration, aetiology and prognostic.

RESULTS

Symptomatic or criptogenetic aetiology was present in 53% of children and idiopathic in 47%. 27% of episodes of status epilepticus were induced by fever. The most common neurological sequel was epilepsy (onset of new epilepsy in 20%; aggravated in 25%). Two children (10%) had major neurological sequelae after status epilepticus.

CONCLUSION

In our study the duration of status epilepticus and sequelae seems to be related with aetiology.

Attempts to pharmacologically modulate prolactin levels and type 1 autoimmune diabetes in the non-obese diabetic (NOD) mouse

Prolactin (PRL) is well known for its stimulatory effects on various components of the immune response. Experimentally induced high levels of PRL have been shown to correlate with the worsening of several autoimmune diseases. In contrast, lowering PRL levels may protect from the autoimmune process. We investigated in both sexes of NOD mice a spontaneous model of autoimmune type 1 diabetes, the effects of two drugs, a dopaminergic agonist, bromocriptine (BRC, 10 mg/kg), which is assumed to inhibit PRL secretion, and a dopaminergic antagonist, metoclopramide (MCP, 5 mg/kg), which in contrast stimulates PRL secretion, on the incidence of diabetes, the severity of insulitis, and PRL and glucose levels. Chronic treatment of NOD mice with MCP slightly aggravated development of diabetes. The dopamine antagonist tended to accelerate the onset of diabetes in females and significantly increased the number of islets with peri-insulitis in both sexes. The weak deleterious effects exerted by MCP in NOD mice may be related to its stimulatory action on PRL release. Contrary to the expected results, the dopamine agonist BRC did not protect from autoimmune diabetes. In contrast, the drug appeared to accelerate diabetes onset in males and significantly increased the number of islets showing insulitis in both sexes. This study underlines the complexity of the action of BRC which in NOD mice only transiently inhibits the release of PRL. Moreover, the aggravating actions of BRC may be related to the marked hyperglycemic effect of the drug observed in male and female NOD mice.