Association between dietary patterns and renal function in a cross-sectional study using baseline data from the ELSA-Brasil cohort

Previous analyses of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) identified four main dietary patterns (DP). The aim of this study was to explore the association between the previously defined DP and renal function (RF). A cross-sectional study using the ELSA-Brasil baseline data was carried out. DP (“traditional”, “fruits and vegetables”, “bakery”, and “low sugar/low fat), metabolic syndrome (MS) using the Joint Interim Statement criteria, microalbuminuria (MA), and glomerular filtration rate (eGFR) through the CKD-EPI equation were evaluated. Abnormal RF was defined as eGFR<60 mL·min^-1·(1.73 m²)^-1 and MA≥3.0 mg/dL. Factors associated with RF were determined and mediation analysis was performed to investigate the association between DP, MS, and RF. A total of 15,105 participants were recruited, with a mean age of 52±9 years; 8,134 participants (54%) were females. The mediation analysis identified indirect associations between “bakery” and “fruits and vegetables”, and both were associated with decreased eGFR and albuminuria in both genders, compared with “traditional” and “low sugar/low fat” patterns in the general population. There was a direct association of the “bakery” pattern with MA in men (OR: 1.17, 95%CI: 1.92-1.48). The “fruits and vegetables” pattern also showed a direct association with reduced eGFR in women (OR: 1.65, 95%CI: 1.28-2.12), although there was no significance after adjustment. The “fruits and vegetables” and “bakery” DPs were associated with renal dysfunction. The only independent, direct association was between “bakery” DP and MA in men, raising concerns about DP and renal damage in men.

Isolation and characterization of 2-pyridone alkaloids and alloxazines from Beauveria bassiana

Two novel compounds bearing heterocyclic nitrogen, 2-pyridone alkaloid (1) and alloxazine derivative (2), along with the known pretenellin B (3), pyridovericin (4) and lumichrome (5) were isolated from a culture of the entomopathogenic fungal strain Beauveria bassiana. The chemical structures of 2-pyridone alkaloid and alloxazine derivative were established on the basis of the interpretation of spectroscopic data. The isolated compounds were evaluated in a panel of five cancer cell lines and pyridovericin exhibited cytotoxicity (IC₅₀, μM) against cancer cell lines: HL-60 (25.9 ± 0.3), HCT8 (34.6 ± 3.6), MDA-MB435 (34.8 ± 3.8) and SF295 (31.1 ± 0.6). Considering that other pyridone compounds display good cytotoxic activity, it would be suggested to obtain new semi synthetic derivatives of pyridovericin, for the development of new cytotoxic chemical entities.

Decreased circulating thrombomodulin is improved by tadalafil therapy in hypoxemic patients with advanced pulmonary arterial hypertension

INTRODUCTION

Advanced pulmonary arterial hypertension (PAH) in patients with congenital cardiac communications and right-to-left shunting (Eisenmenger syndrome - PAH-ES) is associated with hypoxemia and decreased circulating levels of thrombomodulin (TM), probably reflecting decreased endothelial TM production. The combination of these two factors has been shown to induce fibrin deposition, with increased risk of thrombosis, a well known complication in this syndrome.

PATIENTS AND METHODS

We tested the hypothesis that vasodilator therapy with the phosphodiesterase-5 inhibitor tadalafil, an approved drug for management of PAH could improve endothelial dysfunction markers, in particular plasma TM, in addition to improving the physical capacity (expected effect of pulmonary vasodilatation) in PAH-ES patients. This was a prospective observational study of treatment-naïve patients subjected to specific PAH therapy. Fifteen patients aged 12 to 51years (median 30years) were treated for 6months with a single daily dose of 40mg oral tadalafil. The physical capacity (distance walked during the 6-min walk test - 6MWD), systemic oxygen saturation and laboratory parameters were measured at baseline, and 90days and 180days of treatment.

RESULTS

Plasma TM, which was decreased at baseline compared to controls (p<0.001) increased at 90 and 180days (p=0.003), and this was directly related (r=0.57, p=0.026) to improvement of oxygen saturation (p=0.008). Heightened baseline tissue-type plasminogen activator decreased during treatment (p=0.010), while heightened von Willebrand factor antigen remained unchanged. The 6MWD improved significantly (p<0.001).

CONCLUSION

Tadalafil therapy improved circulating TM and tissue-type plasminogen activator, in addition to improving the physical capacity and oxygen saturation in PAH-ES patients.

Plasmatic ADAMTS-13 metalloprotease and von Willebrand factor in children with cyanotic congenital heart disease

Changes in plasma von Willebrand factor concentration (VWF:Ag) and ADAMTS-13 activity (the metalloprotease that cleaves VWF physiologically) have been reported in several cardiovascular disorders with prognostic implications. We therefore determined the level of these proteins in the plasma of children with cyanotic congenital heart disease (CCHD) undergoing surgical treatment. Forty-eight children were enrolled (age 0.83 to 7.58 years). Measurements were performed at baseline and 48 h after surgery. ELISA, collagen-binding assays and Western blotting were used to estimate antigenic and biological activities, and proteolysis of VWF multimers. Preoperatively, VWF:Ag and ADAMTS-13 activity were decreased (65 and 71% of normal levels considered as 113 (105-129) U/dL and 91 ± 24% respectively, P < 0.003) and correlated (r = 0.39, P = 0.0064). High molecular weight VWF multimers were not related, suggesting an interaction of VWF with cell membranes, followed by proteolytic cleavage. A low preoperative ADAMTS-13 activity, a longer activated partial thromboplastin time and the need for cardiopulmonary bypass correlated with postoperative bleeding (P < 0.05). Postoperatively, ADAMTS-13 activity increased but less extensively than VWF:Ag (respectively, 2.23 and 2.83 times baseline, P < 0.0001), resulting in an increased VWF:Ag/ADAMTS-13 activity ratio (1.20 to 1.54, respectively, pre- and postoperative median values, P = 0.0029). ADAMTS-13 consumption was further confirmed by decreased ADAMTS-13 antigenic concentration (0.91 ± 0.30 to 0.70 ± 0.25 µg/mL, P < 0.0001) and persistent proteolysis of VWF multimers. We conclude that, in pediatric CCHD, changes in circulating ADAMTS-13 suggest enzyme consumption, associated with abnormal structure and function of VWF.

Plasma von Willebrand factor as a predictor of survival in pulmonary arterial hypertension associated with congenital heart disease

Biomarkers have been identified for pulmonary arterial hypertension, but are less well defined for specific etiologies such as congenital heart disease-associated pulmonary arterial hypertension (CHDPAH). We measured plasma levels of eight microvascular dysfunction markers in CHDPAH, and tested for associations with survival. A cohort of 46 inoperable CHDPAH patients (age 15.0 to 60.2 years, median 33.5 years, female:male 29:17) was prospectively followed for 0.7 to 4.0 years (median 3.6 years). Plasma levels of von Willebrand factor antigen (VWF:Ag), tissue plasminogen activator (t-PA) and its inhibitor (PAI-1), P-selectin, reactive C-protein, tumor necrosis factor alpha, and interleukin-6 and -10 were measured at baseline, and at 30, 90, and 180 days in all subjects. Levels of six of the eight proteins were significantly increased in patients versus controls (13 to 106% increase, P < 0.003). Interleukin-10 level was 2.06 times normal (P = 0.0003; Th2 cytokine response). Increased levels of four proteins (t-PA, PAI-1, P-selectin, and interleukin-6) correlated with disease severity indices (P < 0.05). Seven patients died during follow-up. An average VWF:Ag (mean of four determinations) above the level corresponding to the 95th percentile of controls (139 U/dL) was independently associated with a high risk of death (hazard ratio = 6.56, 95%CI = 1.46 to 29.4, P = 0.014). Thus, in CHDPAH, microvascular dysfunction appears to involve Th2 inflammatory response. Of the biomarkers studied, plasma vWF:Ag was independently associated with survival.

In vivo and in vitro anti-inflammatory and anti-nociceptive activities of lovastatin in rodents

Statins are among the most prescribed drugs in recent clinical practice. They are also known for their pleiotropic actions, which are independent of their lipid-lowering properties. The effect of lovastatin was investigated against carrageenan-induced paw edema in male Wistar rats (200-250 g) and on leukocyte migration, as measured by carrageenan-induced peritonitis in male Swiss mice (20-25 g), which are models of acute inflammation. Lovastatin (administered 1 h prior to carrageenan), at oral doses of 2, 5, and 10 mg/kg, markedly attenuated paw edema formation in rats at the 4th hour after carrageenan injection (25, 43, and 37% inhibition, respectively). Inhibitions of 20, 45 and 80% were observed in the leukocyte migration, as evaluated by carrageenan-induced peritonitis in mice with lovastatin doses of 0.5, 1 and 5 mg/kg, as compared to controls. Furthermore, lovastatin (administered 1 h before initiation) reduced the nociceptive effect of the formalin test in mice, at both phases, at doses of 2, 5, and 10 mg/kg: first phase (51, 65, and 70%, respectively) and second phase (73, 57, and 66% inhibition of licking time, respectively). The anti-nociceptive activity of lovastatin was inhibited by naloxone (3 mg/kg, sc). Lovastatin (0.01, 0.1, and 1 µg/mL) inhibited by 23, 79, and 86%, respectively, the release of myeloperoxidase from human neutrophils. Leukocyte (predominantly neutrophils) infiltration was almost completely reduced by lovastatin treatment, as observed in the model of acute paw edema with hematoxylin and eosin staining. In addition, lovastatin decreased the number of cells expressing tumor necrosis factor-α (TNF-α) and the inducible form of nitric oxide synthase (iNOS) activity. Therefore, the alterations in leukocyte activity and cytokine release could contribute to the anti-inflammatory activity of lovastatin.

Frequency of 22q11.2 microdeletion in sporadic non-syndromic tetralogy of Fallot cases

BACKGROUND

Tetralogy of Fallot (TOF) is a congenital conotruncal heart defect commonly found in DiGeorge (DGS) and velocardiofacial (VCFS) syndromes. The deletion of chromosome 22q11 has also been demonstrated in sporadic or familial cases of TOF. The aim of the present study was to investigate the frequency of del22q11 in patients with non-syndromic TOF seen at a tertiary Pediatric Cardiology care center.

METHOD

One hundred and twenty three non-syndromic TOF patients were selected and evaluated by history, physical examination and review of medical records. Venous blood was drawn for genomic DNA extraction after informed consent 22q11 microdeletion diagnosis was conducted through a standardized SNP genotyping assay and consecutive homozygosity mapping. Phenotype-genotype correlations regarding cardiac anatomy were conducted.

RESULTS

We evaluated 123 non-syndromic TOF patients for a 22q11 deletion. 105 (85.4%) patients presented pulmonary stenosis and 18 (14.6%) had pulmonary atresia. Eight patients (6.5%) were found to have a deletion. Of the deleted patients, three (37.5%) presented pulmonary atresia. We have verified a tendency towards a higher prevalence of pulmonary atresia when comparing TOF patients with and without 22q11 microdeletion.

CONCLUSIONS

22q11.2 deletion in non-syndromic TOF patients is present in approximately 6% of patients. We suggest a tendency towards a higher prevalence of pulmonary atresia in non-syndromic TOF patients with 22q11 microdeletion. Molecular genetic screening of non-syndromic TOF patient may be important for the correct care of these patients and a more specific genetic diagnostic and counseling.

PCR screening for 22q11.2 microdeletion: Development of a new cost-effective diagnostic tool

BACKGROUND

Del22q11.2 syndrome is the most frequent known chromosomal microdeletion syndrome. Previous studies suggest that a substantial number of patients with congenital heart disease have a 22q11 deletion. The molecular diagnosis of Del22q11.2 is usually made by fluorescence in situ hybridization, an expensive and not widely available technique. We developed an efficient and cost-effective PCR SNP assay designed for the screening of 22q11.2 deletion through consecutive homozygosity.

METHODS

Through the screening of dbSNP we have selected SNP markers located in the 22q11.2 microdeleted region. Population heterozygosities were determined in 213 normal individuals. Designed assays consisted of PCR amplification followed by restriction enzyme digestion. Fragments generated were visualized on agarose gel and genotyped.

RESULTS

Selected markers were: rs5748411, rs2238778, rs4819523 and rs4680. All selected markers were localized in the 22q11.2 deleted region. Allele and genotype frequencies of all selected markers were under Hardy-Weinberg equilibrium. Selected SNPs were not in linkage disequilibrium. Predicted assay specificity was estimated to be 92.86% in the Brazilian population.

CONCLUSIONS

The use of consecutive homozygosity in this SNP-based diagnostic test may be used as a cost-effective tool in reference molecular genetics laboratories.

Knowledge about transplantation and attitudes toward organ donation: a survey among medical students in northeast Brazil

During the registration for the second semester of 2002, 779 of the 1001 students from the Medical School, Federal University of Bahia, Brazil, answered an anonymous multiple-choice questionnaire including demographic variables, knowledge about transplantation issues, and willingness to donate organs. Mean age was 21.9 +/- 2.9 years (range: 17 to 51 years); 59.5% were men. Regarding the knowledge of which organs and tissues could be transplanted, 99.1% answered kidneys, 96.1% heart, 88.2% liver, 41.1% lung, 24.0% pancreas, 9% bowel, 98.3% corneas, 89.5% bone marrow, 38.1% heart valves, 47.7% skin, and 18.5% bone and tendons. Regarding the criteria of death, 82.4% answered that it is the lack of all brain activity, 8.2% cardiac arrest, 5.2% irreversible coma, and 4.2% did not know. As to the Brazilian transplantation law, 47.3% did not know, 51% had heard about it, and 1.7% answered that they knew the law in detail. As to the willingness to donate organs, 538 (69.2%) were donors. Of 239 nondonors, 51.1% answered the reason for not donating was the lack of confidence in the heath system, 14.3% had no knowledge of the matter, 17.7% were concerned about organ removal before brain death, and 1.7% for religious reasons. The percentage of those willing to donate organs was greater among spiritualists than among Catholics and Protestants. The results of this study support a greater emphasis on providing information regarding transplantation in medical schools to improve the knowledge of future heath care professionals about transplantation and organ donation issues.

One-year follow-up of the effects of sildenafil on pulmonary arterial hypertension and veno-occlusive disease

We hypothesized that chronic oral administration of the phosphodiesterase-5 inhibitor sildenafil could improve the exercise capacity and pulmonary hemodynamics in patients with pulmonary arterial hypertension (PAH) on the basis of previous short-term studies. We tested this hypothesis in 14 subjects with PAH, including seven patients with the idiopathic form and seven patients with atrial septal defects, but no other congenital heart abnormalities. Patients were subjected to a 6-min walk test and dyspnea was graded according to the Borg scale. Pulmonary flow and pressures were measured by Doppler echocardiography. Patients were given sildenafil, 75 mg orally three times a day, and followed up for 1 year. Sildenafil therapy resulted in the following changes: increase in the 6-min walk distance from a median value of 387 m (range 0 to 484 m) to 462 m (range 408 to 588 m; P < 0.01), improvement of the Borg dyspnea score from 4.0 (median value) to 3.0 (P < 0.01), and increased pulmonary flow (velocity-time integral) from a median value of 0.12 (range 0.08 to 0.25) to 0.23 (range 0.11 to 0.40; P < 0.01) with no changes in pulmonary pressures. In one patient with pulmonary veno-occlusive disease diagnosed by a lung biopsy, sildenafil had a better effect on the pulmonary wedge pressure than inhaled nitric oxide (15 and 29 mmHg, respectively, acute test). He walked 112 m at baseline and 408 m at one year. One patient died at 11 months of treatment. No other relevant events occurred. Thus, chronic administration of sildenafil improves the physical capacity of PAH patients and may be beneficial in selected cases of veno-occlusive disease.

Race and glomerulonephritis in patients with and without hepatosplenic Schistosomiasis mansoni

BACKGROUND/AIMS

United States investigators have shown evidence of higher susceptibility to focal segmental glomerulosclerosis (FSGS) in blacks than in whites. This association between race and FSGS has not been assessed outside the US. The present study assesses the association between race and type of glomerulonephritis in a sample of Brazilian patients, taking into account the presence of the hepatosplenic form of Schistosomiasis mansoni (HSM).

METHODS

Eighty patients with focal segmental glomerulosclerosis (FSGS) were compared to 50 with membranoproliferative glomerulonephritis (MPGN). The association between race (i.e. black versus white) and type of glomerulonephritis was adjusted for age, gender and HSM by logistic regression.

RESULTS

Blacks were more likely than whites to have FSGS (as compared to MPGN), both among patients with HSM (odds ratio (OR) = 2.67; 95% confidence interval (CI) = 0.81 - 8.81) and without HSM (OR = 2.19; 95% CI = 0.79 - 6.05). After adjustment for age, gender and HSM, the odds of FSGS remained significantly greater for blacks (OR = 2.49; 95% CI = 1.05 - 5.95).

CONCLUSION

The increased likelihood of FSGS in Brazilian blacks is consistent with findings from US patients. The association between race and type of glomerulonephritis was similar between patients with and without HSM. Future investigations should focus on the mediators factors that might explain these findings.

A mathematical framework for group analysis of von Willebrand factor multimeric composition following luminography

The objective of the present study was to establish a method for quantitative analysis of von Willebrand factor (vWF) multimeric composition using a mathematical framework based on curve fitting. Plasma vWF multimers from 15 healthy subjects and 13 patients with advanced pulmonary vascular disease were analyzed by Western immunoblotting followed by luminography. Quantitative analysis of luminographs was carried out by calculating the relative densities of low, intermediate and high molecular weight fractions using laser densitometry. For each densitometric peak (representing a given fraction of vWF multimers) a mean area value was obtained using data from all group subjects (patients and normal individuals) and plotted against the distance between the peak and IgM (950 kDa). Curves were constructed for each group using nonlinear fitting. Results indicated that highly accurate curves could be obtained for healthy controls and patients, with respective coefficients of determination (r2) of 0.9898 and 0.9778. Differences were observed between patients and normal subjects regarding curve shape, coefficients and the region of highest protein concentration. We conclude that the method provides accurate quantitative information on the composition of vWF multimers and may be useful for comparisons between groups and possibly treatments.

Hypertension in black people: pathophysiology and therapeutic aspects

Salt sensitivity is regarded as an important contributor to the higher risk of hypertension in black people as compared with whites. This finding is in agreement with a better response to diuretics than to monotherapy with angiotensin-converting enzyme (ACE) inhibitor in black subjects. It is important to remember that the hypotensive effect of ACE inhibitor is augmented in patients on a thiazide diuretic. Moreover, the antihypertensive response to a specific drug varies among black patients. Thus, ACE inhibitors should also be viewed as important options to treat hypertensive black subjects. Results from clinical trials support an emphasis on lifestyle modification and a more intensive blood pressure lowering by pharmacological interventions to reduce the large black-white gap in cardiovascular events and end-stage renal disease (ESRD) attributed to hypertension.

Use of oral antihypertensive medication preceding blood pressure elevation in hospitalized patients

OBJECTIVE

To evaluate the frequency of oral antihypertensive medication preceding the increase in blood pressure in patients in a university hospital, the drug of choice, and the maintained use of antihypertensive medication.

METHODS

Data from January to June 1997 from the University Hospital Professor Edgard Santos Pharmacy concerning the prescriptions of all inpatients were used. Variables included in the analysis were: antihypertensive medication prescription preceding increase in blood pressure, type of antihypertensive medication, gender, clinical or surgical wards, and the presence of maintained antihypertensive medication.

RESULTS

The hospital admitted 2,532 patients, 1,468 in surgical wards and 818 in medical wards. Antihypertensive medication prescription preceding pressure increase was observed in 578 patients (22.8%). Nifedipine was used in 553 (95.7%) and captopril in 25 (4.3%). In 50.7% of patients, prescription of antihypertensive medication was not associated with maintained antihypertensive medication. Prescription of antihypertensive drugs preceding elevation of blood pressure was significantly (p<0.001) more frequent on the surgical floor (27.5%; 405/1468) than on the medical floor (14.3%; 117/818). The frequency of prescription of antihypertensive drugs preceding elevation of blood pressure without maintained antihypertensive drugs and the ratio between the number of prescriptions of nifedipine and captopril were greater in surgical wards.

CONCLUSION

The use of antihypertensive medication, preceding elevation of blood pressure (22.8%) observed in admitted patients is not supported by scientific evidence. The high frequency of this practice may be even greater in nonuniversity hospitals.

Reduction in diastolic blood pressure and cardiovascular mortality in nondiabetic hypertensive patients. A reanalysis of the HOT study

OBJECTIVE

To use published Hypertension Optimal Treatment (HOT) Study data to evaluate changes in cardiovascular mortality in nondiabetic hypertensive patients according to the degree of reduction in their diastolic blood pressure.

METHODS

In the HOT Study, 18,700 patients from various centers were allocated at random to groups having different objectives of for diastolic blood pressure: </=90 (n=6264); </=85 (n=6264); </=80mmHg (n=6262). Felodipine was the basic drug used. Other antihypertensive drugs were administered in a sequential manner, aiming at the objectives of diastolic blood pressure reduction.

RESULTS

The group of nondiabetic hypertensive subjects with diastolic pressure</=80mmHg had a cardiovascular mortality ratio of 4.1/1000 patients/year, 35.5% higher than the group with diastolic pressure </=90mmHg (cardiovascular mortality ratio, 3.1/1000 patients/year). In contrast, diabetic patients allocated to the diastolic pressure objective group of </=80mmHg had a 66.7% reduction in cardiovascular mortality (3.7/1000 patients/year) when compared with the diastolic pressure group of </=90mmHg (cardiovascular mortality ratio, 11.1/1000 patients/year).

CONCLUSION

The results indicate that in hypertensive diabetic patients reduction in diastolic blood pressure to levels </=80mmHg decreases the risk of fatal cardiovascular events. It remains necessary to define the level of diastolic blood pressure </=90mmHg at which maximal reduction in cardiovascular mortality is obtained for nondiabetics.

The association between serum potassium at hospital admission and the case-fatality rate of leptospirosis in men

Severe leptospirosis affects predominantly males and presents a high susceptibility to hypokalemic acute renal failure. As hypokalemia and hyperkalemia induce severe complications, it is important to evaluate if the initial serum potassium is an independent risk factor for death in leptospirosis. The medical records of 1016 patients hospitalized with the diagnosis of leptospirosis were reviewed. The analysis was restricted to 442, according to the following criteria: male, 18 years or older, information about death or hospital discharge and recorded values of serum potassium, serum creatinine and duration of symptoms at admission. Potassium values lower than 3.5 mEq/L (hypoK), 3.5-5 mEq/L (normoK) and above 5 mEq/L (hyperK) were detected in 180, 245 and 17 patients, respectively. The death rate increased with serum potassium: 11.1% in the hypoK, 14.7% in the normoK and 47.1% in the hyperK group (p = 0.002). In a logistic regression model (normoK as referent), including age, creatinine and duration of symptoms, hypoK was not associated with increased death rate (odds ratio (OR) = 0.80; p > 0.1). On the other hand, hyperK showed a significant association with increased risk of death (OR = 3.95, p = 0.021). In conclusion, in this sample of men with leptospirosis initial serum potassium was positively and independently correlated with the risk of in-hospital death.

Comparative study of bacterial infection prevalence between cirrhotic patients with and without upper gastrointestinal bleeding

Bacterial infection is a frequent complication in patients with chronic liver disease, mainly during the advanced stages. There is evidence that the main factors that contribute to a predisposition to infection in cirrhotic patients are related to hepatic failure with consequent immunodeficiency. Invasive procedures (diagnostic or therapeutic) can predispose to bacterial infections, and upper gastrointestinal bleeding (UGB) is considered a potentially important risk factor. A group of cirrhotic patients (child B and C Pugh groups) were evaluated retrospectively by chart reviews regarding the prevalence of bacterial infection during hospitalization to determine whether UGB was a risk factor. An infection was considered present if a specific organ system was identified or if fever (> 38(o)C) persisted for more than 24 hours with associated leukocytosis. Spontaneous bacterial peritonitis was based on classical criteria. Eighty-nine patients were evaluated. Fourty-six patients presented with UGB, and 43 patients had no UGB (control). There were infections recorded in 25/46 (54%) patients with UGB, and 15/43 (35%) in those without UGB (p=0.065). The ratio of the number of infections/admitted patients, was significantly larger in the group with UGB (0.78 +/- 0.89 vs. 0.39 +/- 0.62; p=0.028) since patients had more than one infection. In the UGB group compared to non UGB group, ascites was more frequent (67% vs. 42%; p=0.027); they were more likely to have undergone endoscopic procedures (p<0.001) and the mean +/- SD for platelets count was smaller (96,114 +/- 57,563 vs 145,674 +/- 104,083; p=0.007). The results show that UGB is an important contribution to bacterial infection among Child B and C cirrhotic patients.

[Severe forms of leptospirosis: clinical, demographic and environmental aspects]

Characteristics of 1,016 patients hospitalized with leptospirosis in the Hospital Couto Maia, Salvador, BA, Brazil, between 1993 and 1997 are described. Higher pluviometric precipitation was related to an increase in the number of hospitalizations during the following month. Males corresponded to 81.1% (824/1,016) of these; mean age was 35.7+/-15.4 years. Almost 94% (778/829) of the 829 patients with information about race were black or mulatto (mixed race). For ages 18 years or above, almost 93% had not completed high school level. The mean incubation period was estimated as 6.3+/-3.9 days. Average duration of symptoms was 6.1+/-2.4 days. Hemorrhagic events corresponded to 14.3% (145/1,016). The case-fatality rate among 1,009 patients that were not transferred was 14.2% (143/1,009). Renal failure was the attributable cause of death in 76.2% (109/143). The data indicate that leptospirosis is closely related to lower socioeconomic levels, and that higher pluviometric precipitation antecedes the outbreaks.

Chest radiograph abnormalities in patients hospitalized with leptospirosis in the city of Salvador, Bahia, Brazil

This study was designed to estimate the prevalence of pulmonary radiograph abnormalities and describe the distribution of the patterns of radiographic alterations among patients hospitalized with leptospirosis. Chest radiographs of 139 patients hospitalized with leptospirosis in Couto Maia Hospital, in Salvador, Bahia, Brazil, between July, 1997, and July, 1999, were analyzed. The radiographs were requested soon after hospital admission, independent of the clinical manifestations of the patients. Only the first radiograph was considered. Pulmonary radiograph alterations were recorded in 35/139 patients (25.2%); 95% mid-point confidence interval = 18.5% to 32.9%. Among the patients with radiograph alterations, alveolar infiltrate was seen in 26/35 (74.3%). The lesions were bilateral in 54.3% and located in the inferior lobes in 45.5%. Pleural effusion, represented by blunting of the costo-phrenic angle, was detected in 8.6% of the patients. The pattern of the pulmonary alterations, predominantly bilateral alveolar infiltrates, is consistent with the evidence that the basic pulmonary alteration in leptospirosis is a generalized capillaritis.

Facial nerve palsy associated with leptospirosis

This case report describes the findings of a 27-year-old black male from Bahia, Brazil, who developed facial palsy during the convalescence phase of leptospirosis. The patient recovered without neurological sequel. This work calls attention to a possible association between leptospirosis and facial palsy.

Differential effects of enzymatic treatments on the storage and secretion of von Willebrand factor by human endothelial cells

Enzymatic treatment used for passaging of endothelial cells may induce release of von Willebrand factor (vWF). Decreased ability to replenish intracellular stores results in decreased secretion of vWF in later passages of cells. Since both trypsin and pancreatin complex have been used for passaging endothelial cells, we analyzed the effects of successive passaging with these two enzyme preparations on the storage and secretion of vWF by human umbilical vein endothelial cells (HUVECs). Measurements were performed after the second to fifth passages. Cytoplasmic vWF was analyzed by indirect immunofluorescence and secreted vWF was measured in the supernatant of cultured HUVECs by ELISA. In trypsin-passaged cells, secreted vWF decreased progressively from passages 2 to 5. Respective concentrations were 355.0 +/- 30.4, 201.0 +/- 84.5, 150.0 +/- 1.4 and 120.5 +/- 38.9 ng vWF/10(5) cells. Comparatively, pancreatin-passaged cells secreted even less vWF protein (P = .001) at passages 4 and 5 (108.5 +/- 12.0 and 100.0 +/- 4.2 ng/10(5) cells, respectively) and had less vWF-positive cytoplasmic granules per cell. Thus, in experiments involving measurements of endothelial vWF, the use of low passage cells is recommendable and passaging with a pure trypsin preparation appears to be more appropriate.

Community acquired pneumonia among pediatric outpatients in Salvador, Northeast Brazil, with emphasis on the role of pneumococcus

Pneumonia is one of the leading causes of hospitalization and death among children in developing countries, and mortality due to pneumonia has been associated with S. pneumoniae infection. This investigation was designed to describe the antimicrobial susceptibility and serotype patterns of pneumococcal strains recovered from the blood of children with community-acquired pneumonia (CAP) and to assess the clinical findings of pneumococcal bacteremic patients with pneumonia. In a 26 month prospective study, blood cultures were obtained as often as possible from children (<16 years of age) diagnosed with CAP in two emergency rooms. Antimicrobial drug susceptibility tests and serotyping were performed when pneumococcus was identified. We studied 3,431 cases and cultured blood samples from 65.5% of those. Pneumococcus was recovered from 0.8% of the blood samples. The differences in age, somnolence, wheezing and hospitalization among children with and without pneumococcal bacteremia were statistically significant. Pneumococcal bacteremia was age-related (mean 1.63 +/- 1.55; median 0.92) and associated with somnolence and hospitalization among children with CAP. One strain was recovered from pleural fluid. Penicillin resistance was detected in 21.0% (4/19) of the strains at an intermediate level, whereas 63.0% of the strains were resistant to trimethoprim-sulfamethoxazole. The most common serotypes were 14 and 6B, and these serotypes included the resistant strains. Eight of our 18 isolates from blood were of types included in the heptavalent conjugate pneumococcal vaccine, recently licensed in the USA.

[Association between race and incidence of end-stage renal disease secondary to glomerulonephritis: influence of the histologic type and presence of arterial hypertension]

OBJECTIVE

To assess, retrospectively, the association between race and incidence of end-stage renal disease (ESRD) in patients with glomerulonephritis in a University Hospital of Bahia, Brazil.

METHODS

The sample was comprised of 79 patients with focal segmental glomerulosclerosis (FSG), 50 with membranoproliferative glomerulonephritis (MPGN) and 49 with other types of glomerulonephritis (OTGN), followed-up between 1970 and 1996 for at least 6 months. It was not included patients with acute glomerulonephritis, minimal change disease, crescentic glomerulonephritis, connective tissue diseases or patients with serum creatinine level greater than or equal to 4.0 mg/dl. The patients were classified according to race as caucasian (white), mulatto or negro. For patients older than 18 yr, not taking antihypertensives drugs, hypertension was defined as a mean of three blood pressure measurements greater than or equal to 140 mmHg for systolic or 90 mmHg for diastolic; for ages </= 18 years. The definition was based on criteria recommended by the Task Force on Blood Pressure in Children.

RESULTS

In the normotensive group, the incidence of ESRD was 72% lower in mulattos and negroes (relative risk (RR)=0.28; 95% confidence interval (CI)=0.11-0.67). In the group with hypertension, the direction of association between race and ESRD was opposite to that observed in the normotensive group (RR=1.49; 95% CI= 0.68-4.34). The modification in the RR depending on the presence or the absence of hypertension was statistically significant (p=0.01). In the normotensive group the RR shifted toward the null hypothesis after the inclusion of histologic type in the Cox model.

CONCLUSIONS

Among normotensive patients with glomerulonephritis the incidence of ESRD was greater in caucasians (whites) than in negroes or mulattoes. By contrast among hypertensive patients there was a trend for a higher risk of ESRD in negroes. The study suggests that hypertension and the histologic type of glomerulonephritis influence the association between race and ESRD.

Inverse association between skin response to aeroallergens and Schistosoma mansoni infection

BACKGROUND

Helminthic infections and allergic disease are highly prevalent in many areas of the world. It is known that IgE antibodies are involved in the pathogenesis of both helminthiasis and atopy. However, the consequences of the presence of helminthic infections in atopic patients are still not completely understood.

METHODS

Subjects infected by Schistosoma mansoni with more than 200 eggs/g of feces (n = 42) and uninfected subjects (n = 133) were selected from an endemic area of schistosomiasis. The history of allergy and results of the immediate hypersensitivity prick tests with inhalant allergen extracts were registered. Total IgE and IgE specific to S. mansoni and aeroallergens were measured in serum by ELISA.

RESULTS

The proportion of individuals with a positive skin test to allergens was higher in the uninfected group (24.3%) than in the group with more than 200 eggs/g of feces (4.8%). The odds of atopy (defined as a positive test for at least one of the antigens) were 5 times higher (odds ratio = 7.0; 95% confidence interval = 1.6-31.1%; p = 0.01) in the uninfected group, after taking into account the potential influence of gender and age. While there was a tendency for higher total and S. mansoni-specific IgE levels in infected patients, an opposite trend, that is higher aeroallergen-specific IgE, was observed in uninfected subjects.

CONCLUSIONS

There was a strong and statistically significant inverse association between the immediate skin test response to common aeroallergens and infection by S. mansoni. The results indicate that immediate hypersensitivity reactions may be suppressed in S. mansoni-infected individuals.

Prognostic factors of rheumatic mitral stenosis during pregnancy and puerperium

OBJECTIVE

To identify characteristics associated with complications during pregnancy and puerperium in patients with rheumatic mitral stenosis.

METHODS

Forty-one pregnant women (forty-five pregnancies) with mitral stenosis, followed-up from 1991 to 1999 were retrospectively evaluated.

PREDICTOR VARIABLES

the mitral valve area (MVA), measured by echocardiogram, and functional class (FC) before pregnancy (NYHA criteria). Maternal events: progression of heart failure, need for cardiac surgery or balloon mitral valvulotomy, death, and thromboembolism. Fetal/neonatal events: abortion, fetal or neonatal death, prematurity or low birth weight (<2,500 g), and extended stay in the nursery or hospitalization in newborn ICU.

RESULTS

The mean +/- SD of age of the patients was 28.8+/-4.6 years. The eventful and uneventful patients were similar in age and percentage of first pregnancies. As compared with the level 1 MVA, the relative risk (RR) of maternal events was 5.5 (95% confidence interval (CI) =0.8-39.7) for level 2 MVA and 11.4 (95% CI=1.7-74.5) for level 3 MVA. The prepregnancy FC (FC > or = II and III versus I) was also associated with risk for maternal events (RR=2.7; 95% CI=1.4-5.3).MVA and FC were not importantly associated with these events, although a smaller frequency of fetal/neonatal events was observed in patients who had undergone balloon valvulotomy.

CONCLUSION

In pregnant women with mitral stenosis, the MVA and the FC are strongly associated with maternal complications but are not associated with fetal/neonatal events. Balloon mitral valvulotomy could have contributed to reducing the risks of fetal/neonatal events in the more symptomatic patients who had to undergo this procedure during pregnancy.

Massive ocular hemorrhage resulting in blindness in a patient with the sickle cell trait who developed leptospirosis. Case report

This case report describes the findings of a 18 year-old black male from Bahia, a Northeastern state in Brazil, with the sickle cell trait, who developed bilateral hyphema and vitreous hemorrhage with blindness in the course of leptospirosis. The patient started to complain of blurred vision four days after the start of fever and muscular pain and approximately twelve hours after the introduction of penicillin. The severity of the leptospirosis in conjunction with sickle cell trait was considered to be the most likely explanation for this ocular complication.

[Evidence-based medicine: the art of applying scientific knowledge in clinical practice]

This article was written with the objective of describing the concept of Evidence Based Medicine (EBM) and the competences required for its practice. EBM should be viewed as an integration of clinical experience with the ability to analyze and rationally apply the scientific information while taking care of patients. The application of methods and strategies to enhance the scientific background of the physician while taking into account the humanitarian values of the medical profession should contribute to improve the quality of the medical care that is offered in Brazil. The Medical Schools and Associations may play important roles in the promotion of EBM.

Decreased sialic acid content of plasma von Willebrand factor in precapillary pulmonary hypertension

In pulmonary hypertension, defective von Willebrand factor protein (vWF) lacking large multimers is present in circulation. This is associated with evidence of chronic endogenous platelet activation. Since asialo vWF has been shown to promote platelet activation and aggregation, we decided to investigate possible changes in the sialic acid content of plasma vWF in patients with precapillary pulmonary hypertension. vWF-associated sialic acid was measured indirectly as a wheat germ agglutinin-reactive substance (WGA-RS, Western blotting), and directly, as a thiobarbituric acid-reactive substance (TBA-RS, spectrophotometric reading). In the sixteen patients we studied (ages 8-45 yr), circulating vWF concentration was 2.18 times normal (p <0.001). However, patient vWF subunit contained 19% (WGA-RS) to 24% (TBA-RS) less sialic acid than the normal protein (p <0.05 for both determinations). In five patients, vWF-associated sialic acid was below 50% normal. We conclude that circulating vWF is hyposialylated in precapillary pulmonary hypertension and speculate that this might influence its interaction with platelets in vivo in these patients.

Mortality attributed to myocardial infarction in the male and female population of Salvador, BA, between 1981 and 1996

OBJECTIVE

To describe according to gender the trend in mortality attributed to myocardial infarction (MI) in the population of Salvador, Bahia between 1981 and 1996.

METHODS

This study was on mortality due to MI estimates by period and gender of the city of Salvador, Bahia. Data from 1981 to 1996 were stratified by quadrienia, and the percentage reduction in death rate due to MI relative to the preceding period (PRR) was determined. Comparisons between genders were expressed by the male/female death ratio (DR) based on the gender-related PPR.

RESULTS

An overall increase of approximately 8% was observed in the death rate attributed to MI for the period 1985-1988 (89.2/10 5 individuals / year) versus the period 1981-1984 (82.1/10(5)/ year). In the subsequent periods, overall reductions of 10% and 20.3% were observed for the periods 1989-1992 and 1993-1996, respectively. For men, the PPRs were 11.1 in the period 1989-1992 and 22.7% in the period 1993-1996. The PPRs in women were lower: 8.6% and 17.4% between 1989 and 1992, and 1993 and 1996, respectively. Death rate reduction was greater for men than women, then the male/female DR decreased from 1.66 in 1981-1984 to 1.35 in 1993-1996.

CONCLUSION

The results indicate a trend towards a reduction in the death rate attributed to myocardial infarction in the city of Salvador from the second half of the 1980s onwards, striking in men.

Endothelial cell dysfunction correlates differentially with survival in primary and secondary pulmonary hypertension

BACKGROUND

Plasma von Willebrand factor antigen (vWF:Ag) has been used as a marker of endothelial perturbation in a number of vascular disorders. In this study, vWF:Ag was determined as an attempt to evaluate the severity of endothelial cell dysfunction in primary pulmonary hypertension (PPH) and congenital heart disease-associated pulmonary hypertension (CHD-PH) comparatively and to determine its impact on short-term survival.

METHODS AND RESULTS

Clinical, hemodynamic, and biochemical data were obtained from 11 patients with PPH and 24 with CHD-PH. Patient groups were similar in terms of age and pulmonary artery pressure. vWF:Ag was measured by electroimmunodiffusion. Patients were followed up for 1 year and at that time, data collected at the beginning of the study were subjected to univariate and multivariate analyses. vWF:Ag was increased in patients (normal reference value 87% +/- 23% activity, mean +/- SD), with higher levels in the PPH group (231% +/- 89%) in comparison with the CHD-PH group (127% +/- 68%) (P <.001). Multivariate analysis showed that survival was influenced by the underlying cause of pulmonary hypertension and vWF:Ag levels but not by patient age, sex, or pulmonary artery pressure. Seven of 10 nonsurvivors but only 4 of 25 survivors had PPH (P =.007). vWF:Ag was 255% +/- 90% in the nonsurvivor group and 121% +/- 54% in the survivors (P <.001).

CONCLUSIONS

Our findings suggest that short-term survival is related to the severity of endothelial cell dysfunction in pulmonary hypertension. In addition, exceedingly high vWF:Ag levels in PPH might reflect a particular pattern of endothelial cell dysfunction that could be associated with decreased short-term life expectancy in this disorder compared with secondary forms of pulmonary hypertension.

Histoplasmosis presenting as acute respiratory distress syndrome after exposure to bat feces in a home basement

This report describes the clinical and epidemiological findings of an outbreak of histoplasmosis in Brazil involving four persons of the same family, one adult and three children. Contamination by fecal material of bats in the basement of the house was found to be the most likely cause of this outbreak. None of the patients had evidence of immune deficiency. The adult died of acute respiratory distress syndrome. A more severe presentation of the disease in this patient may be partly explained by a heavier exposure to the feces of bats.

Two novel anti-von Willebrand factor monoclonal antibodies

Von Willebrand Factor is a multimer produced by endothelial cells and megakaryocytes, being stored in intracellular organelles, such as the Weibel-Palade bodies and alpha-granules in endothelial cells and platelets, respectively. This molecule acts as a carrier protein for factor VIIIc, involved in the intrinsic pathway of blood coagulation maintaining its stability in circulation. Von Willebrand Factor also plays an important role in platelet aggregation and adhesion to injured vessel wall. It interacts with platelets through two distinct glycoproteins, GPIb and GPIIb/IIIa. We raised two monoclonal antibodies, ECA-3 and ECA-4, against human umbilical vascular endothelial cells that recognize and immunoprecipitate von Willebrand Factor. Interestingly, ECA-4 monoclonal antibody is able to completely inhibit platelet agglutination induced by ristocetin, suggesting that it binds to von Willebrand Factor close to platelet GPIb binding site. The use of monoclonal antibodies to identify von Willebrand Factor binding regions to factor VIII or platelets has been reported by others. In pulmonary hypertension, abnormalities have been detected on the multimeric structure of the molecule as well as on its proteolytic fragments, by using monoclonal antibodies. Moreover, monoclonal antibodies raised against specific regions of von Willebrand Factor molecule may allow studies of functional abnormalities of this protein in inherited and acquired disorders like subtypes of von Willebrand's disease.

Difference in the in-hospital mortality of unstable angina pectoris between men and women

PURPOSE

To assess differences in the in-hospital mortality (HM) rate between men and women with unstable angina pectoris (UA) according to age, depression of the ST segment, history of previous acute myocardial infarction (AMI), and risk factors for coronary heart disease.

METHODS

From October 96 to March 98, 261 patients with UA were selected. Logistic regression models were developed to adjust the association between sex and HM for possible influence of covariables, such as hypertension, diabetes mellitus, dyslipidemia, sedentary lifestyle, smoking, and familial history of early coronary heart disease.

RESULTS

HM due to UA was approximately three times higher in women (9.3%; 12/129) than in men (3.0%; 4/132) accounting for a relative risk of 3.07; 95% confidence interval (CI) = 1.02-9.27. In logistic regression models, the association between sex and death was not significantly altered when the following parameters were considered: age, depression of the ST segment, history of previous AMI and risk factors for coronary heart disease. The nonadjusted and adjusted odds ratio (OR) for the distinct covariables were 3.28 (CI 95% = 1.03-10.45) and 3.14 (CI = 95% = 0.88-11.20), respectively.

CONCLUSION

Similarly to AMI, HM in UA is higher in women than in men. Age, risk factors for coronary heart disease, and depression of the ST segment in the electrocardiogram on patients' admission to the hospital did not significantly influence the association between sex and death.

[Racial differences between patients with focal segmental glomerulosclerosis and membranoproliferative glomerulonephritis from the State of Bahia]

OBJECTIVE

To assess the association between race and type of glomerulonephritis, taking into account age, gender and the presence of hepatosplenic schistosomiasis mansoni.

METHODS

Patients from the Renal Service of the Federal University of Bahia, Brazil, 80 with focal segmental glomerulosclerosis (FSG) and 50 with membranoproliferative glomerulonephritis (MPGN) were compared regarding the distribution of the racial types (black, mulatto, white). Patients with systemic lupus erythematosus or any kind of autoimmune disease were not included in the present analysis. Adjusted comparisons were performed using the Mantel-Haenszel method and a multivariate logistic regression model.

RESULTS

Race was significantly associated with histologic type; the odds of being classified as black or mulatto were approximately 2.4 times higher (odds ratio = 2.43; IC 95% = 1.09-5.45) in patients with FSG than in those with MPGN. The association between race and histologic type was not influenced by the potential effects of age, gender and hepatosplenic schistosomiasis. In the multivariate logistic regression model, race was significantly associated (p = 0.037) with type of glomerulonephritis (odds ratio = 2.54; IC 95% = 1.06-6.06).

CONCLUSION

A higher frequency of negroes and mulattoes in the FSG group (compared with MPGN) in this sample from the State of Bahia is consistent with findings of previous studies from the United States. The data support the possibility of a greater susceptibility to FSG among negroes and mulattoes, independently of age, gender and schistosomiasis. The identification of the mechanisms that determine this racial difference represents an important question for future investigations.

Cytoskeletal organization and incorporation of beta 3 integrin in thrombin-stimulated platelets: effect of acetylsalicylic acid

Platelet stimulation by agonists is followed by changes in cytoskeletal organization that includes actin polymerization and association of the membrane skeleton (which is connected with the integrin alpha IIb beta 3) with the underlying cytoplasmic actin filaments. The effect of orally administered acetylsalicylic acid to healthy volunteers on incorporation of contractile protein and beta 3 integrin into the cytoskeletal core of thrombin-stimulated platelets was studied. Stimulation was followed by increased contractile protein and beta 3 incorporation into the cytoskeleton. Acetylsalicylic acid intake resulted in decreased incorporation of myosin and actin (32% and 20%, respectively), and a decrease (36%) in the association of beta 3 integrin with the cytoskeletal elements was evident. In conclusion, we have shown that acetylsalicylic acid, besides the known inhibitory effect on thromboxane synthesis, promotes changes in the cytoskeletal organization of thrombin-stimulated platelets that could limit thrombus formation.

Severe cat flea infestation of dairy calves in Brazil

An investigation was conducted into a severe flea infestation on dairy calves. Inspection of the dairy revealed a high infestation of Ctenocephalides felis felis on four calves and thousands of fleas in the stable where cows and calves were brought in for milking. A 3-month-old female calf was highly infested with fleas. The animal showed an evident lethargy, weight loss, as well as pale mucous membranes and dehydration. Hematological analysis revealed anemia, with 10% packed cell volume and a 1.72 x 10(6) microl(-1) erythrocyte count. Blood transfusions were performed and the flea infestation was controlled with 1% fipronil pour-on (1 ml/10 kg). The farmer was advised to treat the other calves with fipronil, remove the manure from the stable and spread 1% propoxur powder (100 g/m2) onto the floor of the stable.

Circulating von Willebrand factor antigen as a predictor of short-term prognosis in pulmonary hypertension

STUDY OBJECTIVE

To determine the potential value of plasma von Willebrand factor antigenic activity (vWF:Ag) and other commonly measured clinical variables for predicting which patients with precapillary pulmonary hypertension would be unlikely to survive 1 year.

DESIGN

Prospective clinical study. The data obtained at the beginning of the study were analyzed at the end of the first year of follow-up.

PATIENTS AND METHODS

Forty patients aged 1.2 to 45 years (median, 24 years) entered the study. Eleven patients had primary pulmonary hypertension, and in the remaining ones, pulmonary vascular disease was associated with antiphospholipid syndrome (n = 1), collagen vascular disease (n = 1), schistosomiasis (n = 3), or congenital heart defects (Eisenmenger's syndrome) (n = 24). Plasma vWF:Ag was determined by electroimmunodiffusion, and the results were expressed as the percentage of activity.

RESULTS

Seven of 11 patients with primary pulmonary hypertension but only 4 of 29 patients with secondary pulmonary hypertension died during the follow-up period (p < 0.005). Initial vWF:Ag values were significantly higher in the nonsurvivor group in comparison with the survivors (256.6+/-85.3% and 132.0+/-59.3% activity, respectively; p < 0.0001). The likelihood of fatal outcome as a function of plasma vWF:Ag levels was estimated for primary and secondary pulmonary hypertensive patients using logistic regression analysis. Decreased life expectancy was significantly related to high vWF:Ag levels and an established diagnosis of primary pulmonary hypertension. A plasma vWF:Ag of >240% (p = 0.003) was 54% sensitive and 93% specific for identifying patients who were unlikely to survive 1 year, with an overall predictive value of 75%. No other variables correlated significantly with survival.

CONCLUSION

Plasma vWF:Ag seems to be a useful biochemical index for predicting short-term prognosis in patients with pulmonary hypertension. In contrast to hemodynamic and histopathological predictors of survival, vWF:Ag does not require invasive techniques to be determined. In light of the possibility of false-negative results, serial measurements should be performed over time in patients with vWF:Ag of <240%. This observation proved helpful in two patients in this study.

[Difference of hospital mortality of acute myocardial infarction between men and women treated with primary angioplasty]

PURPOSE

To compare the in-hospital case-fatality rate of men and women submitted to percutaneous transluminal coronary angioplasty (PTCA) as a strategy of reperfusion in acute myocardial infarction (MI).

METHODS

A retrospective cohort study based on information abstracted from medical records of MI patients admitted to a hospital where PTCA is used as the preferred method for early myocardial reperfusion. A total of 83 patients, 35 (42%) women and 48 (58%) men, who met the criteria for early myocardial reperfusion was included in the analysis.

RESULTS

The mean age of women was higher than that of men (66 +/- 10 vs 58 +/- 11 years; p < 0.001). The women also had a higher frequency of diabetes mellitus (37.1% vs 6.4%; p < 0.001). Despite these differences in age and in the frequency of diabetes mellitus, the percentage of patients in whom the PTCA was considered successful was similar between men (83.3%) and women (82.3%). The case-fatality rate was also similar between men and women; 14.6% and 14.3%, respectively.

CONCLUSION

The possibility that the excess risk of death in women with MI may be reduced and even eliminated with the use of PTCA, supports to the need for the development of a clinical trial to assess this question.

Abnormalities in circulating von Willebrand factor and survival in pulmonary hypertension

BACKGROUND

Changes in circulating von Willebrand factor (vWF) have been widely used for evaluating the severity of endothelial dysfunction in vascular disorders. In pulmonary hypertension, quantitative and structural abnormalities in circulating von Willebrand factor have been identified. We therefore hypothesized that these abnormalities could have prognostic implications.

PATIENTS AND METHODS

We studied 30 consecutive medically treated patients with primary (n = 11) or secondary precapillary pulmonary hypertension associated with congenital heart disease (n = 16) or schistosomiasis (n = 3). Plasma antigenic activity of vWF (vWF:Ag) was measured by electroimmunodiffusion. The relative concentration of low molecular weight vWF multimers (vWF:LMW/Total) was determined by Western immunoblotting. Results of initial evaluation were analyzed at the end of the first and third years of follow-up.

RESULTS

Baseline vWF:Ag activity (P <0.0002) and the vWF: LMW/Total ratio (P <0.005) were higher in patients who died during the first year than in survivors. All patients with vWF:Ag activity >250% or a vWF:LMW/Total ratio >70% died in the first year. All 7 patients with vWF:Ag activity <100% were alive at the end of 3 years of follow-up. A vWF:LMW/Total ratio >68% was 67% sensitive and 95% specific for 1-year mortality, with an overall predictive value of 80%. Both vWF:Ag levels and mortality were greater in the patients with primary pulmonary hypertension than in patients with secondary pulmonary hypertension.

CONCLUSION

Patients with pulmonary hypertension who have abnormalities in circulating vWF have reduced 1-year survival. This might affect decisions such as patient assignment to lung transplantation.

[Increase in the frequency of norfloxacin and ciprofloxacin resistance of bacteria isolated from urine culture]

OBJECTIVE

To assess time trends in the frequency of norfloxacin and ciprofloxacin resistance of bacteria isolated from urine culture.

METHODS

Results of all urine cultures with a bacterial growth of at least 10(5) colony-forming units per milliliter, performed at the Renal Service of the Federal University of Bahia, Brazil, from 1983 to 1994 were analyzed. The bacteria considered for this analysis were those most often isolated: Escherichia coli (n = 668), Klebsiella spp. (n = 286), Staphylococcus spp. (n = 186), Proteus spp. (n = 135) and Enterobacter spp. (n = 129).

RESULTS

The frequencies of norfloxacin resistance for the periods 1983-1986, 1987-1990 and 1991-1994 were 3.2%, 5.9% and 9.1%, respectively (p-value < 0.05). The most pronounced increases in the frequencies of norfloxacin-resistance were observed for Klebsiella spp. and Enterobacter spp. The frequency of ciprofloxacin resistance was 7.4% in the period 1985-1989 and 16.5% in the period 1990-1994 (p-value < 0.05). This time trend in ciprofloxacin resistance was more striking for Enterobacter spp. and Staphylococcus spp.

CONCLUSION

The results show a gradual increase in the frequency of norfloxacin and ciprofloxacin resistance of the bacteria most commonly isolated from urine cultures. The influence of previous treatment with quinolones and characteristics of the infecting bacteria on these findings are important questions to to be addressed in future investigations.