Long‐term efficacy, safety, and tolerability of secukinumab in children and adolescents with severe chronic plaque psoriasis: Two‐year results from a Phase III double‐blind, randomised controlled trial

BACKGROUND

Secukinumab has previously demonstrated sustained efficacy and favourable safety for up to 52 weeks in paediatric patients (children and adolescents aged 6 to <18 years) with severe chronic plaque psoriasis (NCT02471144).

OBJECTIVE

To investigate the long-term (104 weeks) efficacy and safety of secukinumab.

METHODS

After 52 weeks, patients continued to receive secukinumab low dose (LD [75/150 mg]) or high dose (HD [75/150/300 mg]). Patients on etanercept (0.8 mg/kg) until Week 52 entered follow-up. Data for patients receiving secukinumab LD from the beginning and those switching to secukinumab LD from placebo ('Any secukinumab' LD) and patients receiving secukinumab HD from the beginning and those switching to secukinumab HD from placebo ('Any secukinumab' HD) are presented.

ASSESSMENTS

Psoriasis Area and Severity Index (PASI) score, PASI (75/90/100) responses, Investigator's Global Assessment modified 2011 (IGA mod 2011) 0/1 response, Children's Dermatology Life Quality Index (CDLQI) score and CDLQI 0/1 response up to Week 104, and, safety up to Week 104 for all patients and up to 4 years for some patients (~320 patient-years [PY] of treatment).

RESULTS

Secukinumab-treated patients showed sustained PASI 75/90/100 and IGA mod 2011 0/1 responses up to Week 104. Throughout the second year of treatment, efficacy was similar for the 'Any secukinumab' LD and HD groups for PASI 75 and IGA mod 2011 0/1 responses. PASI 90/100 responses were mostly comparable between the dose groups up to Week 88, but higher in the 'Any secukinumab' HD than the 'Any secukinumab' LD group at Week 104. Patients achieved a sustained CDLQI 0/1 response that was similar between the 'Any secukinumab' LD (61.1%) and HD (65.0%) groups. Safety data were consistent with the established safety profile of secukinumab.

CONCLUSION

Secukinumab demonstrated sustained long-term efficacy (up to 2 years) and a favourable safety profile (~320 PY of treatment) in paediatric patients with severe chronic plaque psoriasis.

Integrating genetic and clinical data to predict impulse control disorders in Parkinson's disease

BACKGROUND AND PURPOSE

Impulse control disorders (ICDs) are frequent in Parkinson's disease (PD), with associated clinical and genetic risk factors. This study was aimed at analyzing the clinical features and the genetic background that underlie ICDs in PD.

METHODS

We included 353 patients with PD in this study (58.9% men, mean age 62.4 ± 10.58 years, mean age at disease onset 52.71 ± 11.94 years). We used the validated Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease for ICDs screening. Motor, nonmotor, and treatment-related features were evaluated according to the presence of ICDs. Twenty-one variants related to dopaminergic, serotonergic, glutamatergic, and opioid neurotransmitter systems were assessed. Association studies between polymorphisms and ICDs were performed. The combination of clinical and genetic variables was analyzed with receiver operating characteristic curves to assess the predictability of experiencing ICDs.

RESULTS

Impulse control disorders appeared in 25.1% of the cases. Patients with ICDs were younger and presented a higher rate of anxiety. Treatment with dopamine agonists increased the risk of ICDs and it was dose dependent (P < 0.05). Genetic association studies showed that the DOPA decarboxylase gene (DDC), rs1451375, might modulate the risk of ICDs. Plotting the clinical-genetic model, the predictability of ICDs increased 11% (area under curve = 0.80; z = 3.22, P = 0.001) when adding the genotype data for single nucleotide polymorphisms.

CONCLUSIONS

Polymorphisms in DDC might act as risk markers for ICDs in PD. The predictability of experiencing ICDs increased by adding genetic factors to clinical features. It is therefore important to assess the patient's genetic background to identify individuals at risk for ICDs.

0249 Effects of Alcohol Consumption on Sleep-Wake Pattern of a Rat Model of Anxiety

Introduction

Anxiety is an important factor for self-administered alcohol as a tool to reduce its symptoms. However, alcohol is capable to disrupt sleep-wake patterns in subjects with medium- to high-alcohol consumption. We have selectively bred two sublines from Sprague-Dawley rats that differ on its yawning frequency. High-yawning (HY) rats have a mean of 20 yawns/h, whereas the Low-yawning (LY) rats have only 2 yawns/hour. LY rats also showed anxious responses when evaluated on standardized tests. The aim of this study was to assess the changes on sleep-wake patterns after chronic alcohol consumption.

Methods

We used 8 males from HY and LY sublines at 3 months of age, they lived in acrylic cages with water and food pellets available ad libitum under a 12:12 light-dark cycle (lights on at 0700) and temperature of 21±1 °C. All subjects were implanted to record EEG, EMG and EOG to characterize sleep-wake phases. A baseline sleep-wake recording was obtained for 24 h. A solution of 9.6% alcohol was administered as a single source of hydration for seven days and then a second sleep-wake recording was obtained. After that period, an additional bottle containing purified water was available. Position of the bottles was randomly changed daily. Water and alcohol consumption were measured daily for a period of 3 weeks and then a third sleep-wake recording was obtained.

Results

LY rats consumed more alcohol than HY rats (P&lt;0.05), and they had an increase of bouts and duration of slow wave sleep and REM sleep on their active phase after alcohol administration (P&lt;0.05).

Conclusion

LY rats display an anxious behavior and therefore consumed more alcohol compared to HY rats, and only LY rats were susceptible to alcohol effects on sleep on their active phase.

Support

Partially supported by CONACYT grants 243333 and 243247 to CC and JRE, respectively. Grants from VIEP-BUAP 2018 and CA in Neuroendocrinología BUAP-CA-288.

Follicular Development and Secretion of Ovarian Hormones during the Juvenile and Adult Reproductive Lives of the Myelin Mutant taiep Rat: An Animal Model of Demyelinating Diseases

Infertility and reproductive problems have been reported in women with several neurological disorders, for example, demyelination. However, the physiology of such problems has remained unknown so far. The taiep rats are an animal neurological model that initially shows a hypomyelination followed by a progressive demyelination of the central nervous system. This animal has reproductive problems, and the aim of this work is to characterize the follicular development, secretion of ovarian hormones, and presence of noradrenaline in the ovaries of the female taiep rats in the juvenile and adult stages. The taiep rats have low body weight (approximately 19% less than that of SD rats), a delay of 4 days in the age of vaginal opening, and an irregularity in the estrous cycle by the absence or prolongation of some estral cycle stage. In the juvenile stage, we observed a decrease of approximately 44% in the total number of follicles with a 15% increase of atresia and an 80% decrease in the fluorescence intensity of catecholamines in the ovaries, with a 21% increment in plasma concentrations of testosterone. In the adult stage, we observed follicular cysts and a 50% decrease in fluorescence intensity of catecholamines in the ovaries, with changes in the secretion of ovarian hormones, an increase of 20 times in progesterone, and a decrement of a half in estradiol. The demyelination in taiep rats affects follicular development and steroidogenesis in the early stages of the animal's life, and this is maintained until adulthood.

A longitudinal study of verotoxin-producing Escherichia coli in two dairy goat herds

A longitudinal study was conducted on two dairy farms to investigate the pattern of shedding of verotoxin-producing Escherichia coli (VTEC) in goats. Faecal samples were taken from 20 goat kids once weekly during the first 4 weeks of life and then once every month for the next 5 months of life, and from 18 replacement animals and 15 adults once every month for 12 months. The proportion of samples containing VTEC was higher for replacement animals and adults (85.7% and 78.7%, respectively) than for goat kids (25.4%). About 90% of the VTEC colonies isolated from healthy goats belonged to five serogroups (O33, O76, O126, O146 and O166) but the most frequent serogroups of these isolates, except one, were different in the two herds studied. E. coli O157:H7 was found in three goat kids on only one occasion. None of the VTEC isolates, except the three E. coli O157:H7 isolates, was eae-positive. The patterns of shedding of VTEC in goat kids were variable, but, in contrast, most of the replacement animals and adults were persistent VTEC shedders. Our results show that isolates of VTEC O33, O76, O126, O146 and O166 are adapted for colonising the intestine of goats but that, in contrast, infection with VTEC O157:H7 in goats seems to be transient.

[Strabismus and congenital cataracts]

PURPOSE

To study the prevalence, characteristics, indications for and results of strabismus treatment secondary to congenital cataracts.

MATERIALS AND METHODS

This was a retrospective study of 21 cases from 29 with congenital cataracts with strabismus (unilateral in 11 and bilateral in 10 cases). In 20 patients surgery on the cataracts was performed, with an intraocular lens inserted in 15 patients. Botulinum toxin and/or strabismus surgery were deemed to be indicated when the deviation was stable after rehabilitation therapy. A good motor end result was considered when the final deviation was < or =5 degrees, and a good sensorial result was when there was no suppression in the Worth test even without stereopsis in the TNO test.

RESULTS

The strabismus prevalence was 72.4%. Strabismus was present before cataract surgery was performed in 12 cases, 8 with esotropia (ET) and 4 with exotropia (XT). Strabismus which appeared after cataract surgery was classified as 13 ET, 5 XT, 1 ET with vertical anisotropia in <<V>>, and 2 XT with dissociated vertical deviation (DVD). The strabismus angle was variable in 6 patients and was not treated. The other 6 cases required strabismus treatment. Botulinum toxin was injected as the only treatment in 1 patient, strabismus surgery was performed in 4, and strabismus surgery and botulinum toxin were used in another case. The average age at the time of treatment was 5.2 years. The motor result was good in 5 cases (83.3%) and the sensorial result good in two (33.3%).

CONCLUSIONS

Strabismus secondary to congenital cataracts occurred in a significant number of patients and increased after cataract extraction. Esotropia occurred twice as often as exotropia. Strabismus surgery was not required in most of the cases. The motor results were better than sensorial results.

Changes of colour and carotenoids contents during high intensity pulsed electric field treatment in orange juices

Liquid chromatography (LC) was the method chosen to evaluate the effects of high intensity pulsed electric fields (HIPEF), with different electric field intensities (25, 30, 35 and 40 kV/cm) and different treatment times (30-340 micros), on orange juice cis/trans carotenoid contents. In parallel, a conventional heat treatment (90 degrees C, 20 s) was applied to the orange juice in order to compare the effect on the carotenoid contents. HIPEF processing of orange juice is an alternative to the thermal treatment of pasteurization, provided that it is kept refrigerated, because, when the most extreme conditions of this kind of treatment are applied, the decrease in the concentration of carotenoids with vitamin A activity is very small, and also most of the carotenoids identified have a slightly increased concentration after application of the most intense treatments, although always less than in untreated fresh juice. In any case, pasteurization treatment causes a greater decrease in the concentration of most of the carotenoids identified and the carotenoids with vitamin A activity. The total carotenoid concentration decreased by 12.6% in pasteurized orange juice with respect to untreated fresh orange juice, as opposed to decreases of 9.6%, 6.3% or 7.8% when fields of 25, 30 or 40 kV/cm were applied. Orange juice treated with HIPEF shows a greater tendency towards the colour yellow and a lesser tendency towards red with respect to untreated orange juice, while the luminance of the juice remains practically invariable. This tendency is less than in pasteurized orange juice.

Occurrence and preliminary study of antimicrobial resistance of enterococci isolated from dairy goats in Spain

The present study performed in Spain was designed to investigate the occurrence and antimicrobial resistance of enterococci in faecal and bulk tank milk samples from 222 healthy Murciano-Granadina dairy goats reared on 12 farms. Enterococci were isolated in 54.5% and 63.6% of the faecal and bulk tank milk samples, respectively. Enterococci were detected more frequently from goat kids (70%) than from replacement animals (44.4%) and adults (56.4%). Seven species were found in the faecal samples but the most common species detected were Enterococcus faecium (32.3%), Enterococcus faecalis (27.6%) and Enterococcus hiriae (22%). In contrast, only E. faecium and E. faecalis were found in the bulk tank milk samples. According to NCCLS (2002), of the 134 strains studied, 17 (12.7%) were resistant to at least 7 antimicrobials and 14 of these strains were resistant to vancomycin.

Serotypes, virulence genes and intimin types of verotoxin-producing Escherichia coli and enteropathogenic E. coli isolated from healthy dairy goats in Spain

Faecal samples from 222 healthy dairy goats on 12 farms in Spain, as well as bulk tank milk samples of these farms, were screened for the presence of verotoxin-producing Escherichia coli (VTEC) and enteropathogenic E. coli (EPEC). VTEC and EPEC were isolated in 47.7 and 7.7% of the animals, respectively. VTEC were isolated more frequently from adults and replacement animals than from goat kids. In contrast, EPEC were detected more frequently from goat kids than from replacement animals and adults. VTEC or EPEC strains were not detected in the bulk tank milk samples. Although a selective enrichment protocol was used, the serotype O157:H7 was not detected. The most frequent serotypes among the 106 VTEC strains isolated from goats were O5:H-, O76:H19, O126:H8, O146:H21, ONT:H- and ONT:H21. None VTEC strain was eae-positive. The absence of the eae gene in the VTEC strains could indicate that these strains are less virulent for humans that the classical eae-positive enterohaemorrhagic E. coli types. However, 16% of VTEC strains isolated from healthy goats belonged to serotypes associated with haemolytic uraemic syndrome in humans. The ehxA gene was detected in 84.9 and 52.9% of the VTEC and EPEC from goats, respectively. The beta1, theta/gamma2 and zeta were the most frequent intimin types among the 17 EPEC strains studied and the most prevalent serotypes of these strains were O156:H25 and O177:H11. Our data show that in Spain healthy goats are an important reservoir of VTEC and EPEC, and a potential source of infection for humans.

Multiple environmental signals determine the transcriptional activation of the mycoparasitism related gene prb1 in Trichoderma atroviride

Trichoderma atroviride parasitizes a large variety of phytopathogenic fungi. This characteristic has allowed its use as a biological control agent. The production of hydrolytic enzymes appears to be a key element in the parasitic process. Among the enzymes released by Trichoderma, the proteinase Prb1 plays a major role. We show here that the corresponding gene ( prb1) is subject to nitrogen catabolite repression. Accordingly, induction of prb1 transcription by Rhizoctonia solani cell walls and by osmotic stress requires release from a repressed condition, which is determined by nitrogen availability. Furthermore, the transcription pattern of the prb1 gene was not affected when an inhibitor of p38-Hog1, a regulator of the response to osmotic shock, was used. In contrast, a MEK1/2 (MAPK/ERK) inhibitor blocked prb1 transcription in response to nitrogen limitation, indicating that the pathway employed in the nitrogen response involves proteins similar to p42-p44. Fusion of the prb1 promoter to the gfp reporter gene allowed the detection of a novel regulatory element, providing an initial insight into the nature of the sites that control prb1 expression.

Antiphospholipid antibodies: a risk factor for occlusive retinal vascular disorders. Comparison with ocular inflammatory diseases

OBJECTIVE

To evaluate the prevalence of antiphospholipid antibodies (aPL) together with immunological characteristics of patients with occlusive retinal vascular disorders (ORVD) with and without risk factors (systemic arterial hypertension, diabetes mellitus, hyperlipidemia, and embolizing cardiac disease) for retinal occlusions compared to patients with ocular inflammatory diseases (OID) and healthy controls.

METHODS

Sixty-eight patients with ORVD, 45 patients with OID, and 49 healthy persons were prospectively studied. Serologic studies included determination of anticardiolipin antibodies, lupus anticoagulant, antinuclear antibodies (ANA), levels of complement 4 and 3, total hemolytic complement (CH100), and circulating immune complexes (CIC).

RESULTS

Elevated levels of aPL were detected in 16 (24%) patients with ORVD compared to 4 (9%) patients with OID (OR 3.15, p < 0.05) and 4 (8%) controls (OR 3.46, p < 0.05). No significant differences were seen in the prevalence of aPL comparing risk factor-positive patients with ORVD (8 of 33, 24%) to risk factor-free patients with ORVD (8 of 35, 23%). A higher frequency of positive ANA, elevated IgA, and increased CIC were detected in aPL positive patients with ORVD compared to patients with OID.

CONCLUSION

Detection of aPL in patients with ORVD may help determine which patients are eligible for prophylactic treatment. An immunologic profile characterized by high prevalence of ANA, CIC, and elevated IgA distinguishes ORVD patients with aPL from inflammatory ophthalmologic disorders.

[Gemcitabine in the treatment of 4 patients with cholangiocarcinoma]

Cholangiocarcinoma is a biliary tree cancer of unknown etiology, whose symptoms are unspecific and is usually detected in advanced stages. Surgery continues to be the only curative therapy. Median survival in patients with inoperable tumors ranges between 5 and 8 months. There are few studies on the effects of chemotherapy, with a very small response. We report four patients with advanced cholangiocarcinoma, treated with gemcitabine 1000 mg/m2, weekly for 3 weeks every 28 days. There was a stabilization of tumor size and symptoms were alleviated. Toxicity was low and there was a probable prolongation of survival.

Quality assurance of point-of-care testing in the Costa del Sol Healthcare Area (Marbella, Spain)

Traditionally, point-of-care testing (POCT) has been used throughout the healthcare system without the involvement of the central laboratory. After an exhaustive study of the situation of these laboratories in the Costa del Sol Healthcare Area, we designed a quality control program for the POCT. This program targeted the tests done at the points of care throughout the hospital and the Primary Healthcare Area (PHA), using the Joint Commission on Accreditation of Healthcare Organisations (JCAHO) standards for waived testing. We developed two programs: hospital-based tests and ambulatory POCT for outpatients in PHA. The hospital-based POCT apparatus was used for gases, glucose, qualitative urinalysis, Helicobacter pylori detection in gastrointestinal biopsies and coagulation tests. Ambulatory POCT was used to detect glucose, qualitative urinalysis and pregnancy tests. The personnel responsible are nursing staff with no continuing training program. There was no explicit quality control program and most of the results were used as screening except for glucose in the neonatal department. Criteria for selection of kits and devices were basically based on ergonomic and economic evaluation. Therefore, we performed an evaluation of precision and accuracy of two glucose meter devices. We implemented the internal and external quality programs (IQC and EQC) for glucose testing. We elaborated a guide of standard proceedings for quantitative and qualitative POCT and created an annual course for nursing staff. The annual evaluation of the indicators showed 96% for degree of compliance with IQC; 54% of nursing staff participated in the training program; 98% of the glucometers were operating; and 88% agreement between central laboratory and POCT. As there is no previous experience in our healthcare system, this represents a promising new area of working with nurses, who show great interest in participating in these new programs.

[Efficacy of gemcitabine in the gallbladder cancer. Initial experience in 4 cases]

Surgery continues to be the only curative therapy for gallbladder cancer, but useful in very few patients. Mean survival of patients with gallbladder cancer, that are out of the reach of surgery, is 3 months. The few clinical trials of chemotherapy for this disease, report very low success rates. We report four patients with advanced gallbladder cancer, treated with gemcitabine in an intravenous dose of 1000 mg/m2, given in 30 min, once a week during three consecutive weeks, every 28 days. There was a partial response that lasted 40.3 23.2 weeks with a mean survival of 59.75 17 weeks. One patient survives without evidences of disease after 17 months of the diagnosis of an advanced cancer. In all patients, symptoms were alleviated, functional status and quality of life improved. Toxicity was mild and did not require reduction in doses or delay in therapy. Therefore, this medication deserves further investigation for the treatment of gallbladder cancer.

A prospective search for ocular lesions in hospitalized patients with significant bacteremia

The purpose of this study was to determine the prevalence, risk factors, and prognostic value of ocular lesions in unselected patients with bacteremia. A total of 202 bacteremic patients, 101 nonbacteremic septic patients, and 90 nonseptic control patients were compared in a prospective, controlled, observational study. Ocular lesions related to bacteremia were found in 12% of the bacteremic group, 5% of the septic group, and 2% of the control group. Ocular lesions were significantly more frequent in the bacteremic patients than in the control patients (P=.007). The severity of the clinical condition and the presence of fungemia predict independently a higher risk of ocular lesions. Mortality rates among bacteremic patients with and without ocular lesions were, respectively, 32% and 8% (P<.01; OR, 3.99). The asymptomatic nature of most ocular lesions in patients with bloodstream infections and the impossibility of amelioration in most cases lead us to recommend ophthalmologic examination for bacteremic patients only when prognostic information is needed.

Antiphospholipid antibodies and retinal thrombosis in patients without risk factors: a prospective case-control study

PURPOSE

To determine the prevalence of antiphospholipid antibodies and other immunologic abnormalities in patients with occlusive retinal vascular events, exempt from conventional risk factors of retinal thrombosis.

METHODS

Forty patients with retinal vascular occlusion (26 with retinal vein occlusions, eight with arterial occlusions, two with combined venous and arterial occlusions, and four with venous occlusions plus vasculitis), free of main accepted risk factors for retinal thrombosis, were prospectively screened for antiphospholipid antibodies (anticardiolipin-antibodies and lupus anticoagulant) and other immunologic abnormalities. Fourteen patients were younger than 50 years. Prevalence and mean values of antiphospholipid antibodies (aPL) were compared with those in a homogeneous control group of 40 patients.

RESULTS

The prevalence of antiphospholipid antibodies in the study group was 22.5% (nine of 40). Comparison with control group prevalence (5% [two of 40]) showed a statistically significant difference (P = .04). Six patients in the study group disclosed positivity for IgG-anticardiolipin antibodies, one patient for IgM anticardiolipin antibodies, and two patients for both isotypes IgG and IgM anticardiolipin antibodies. The antibody assay for lupus anticoagulant was negative for all patients. Three patients were diagnosed as having primary antiphospholipid antibody syndrome and are undergoing systemic anticoagulant therapy. Relevant immunologic abnormalities were also found (27.5% with antinuclear antibodies, 35% with elevation of circulating immune complexes, 35% with complement deficiency, 30% with positive rheumatoid factor, and 17.5% with positive C-reactive protein). Thirteen patients (32.5%) had more than four parameters altered. No significant association was found between prevalence or mean values of anticardiolipin antibody and patients younger than 50 years.

CONCLUSIONS

The high prevalence of anticardiolipin antibodies in patients with vaso-occlusive retinopathy exempt from conventional risk factors, and the relevant diagnostic and therapeutic implications, lead us to recommend a systematic search for specific antiphospholipid antibodies in such patients.

Immunotherapy with a mass unit Parietaria judaica extract: a tolerance study with evidence of immunological changes to the major allergen Par j 1

Specific immunotherapy with Parietaria judaica pollen extract has been proven to be effective in the treatment of patients with respiratory allergy induced by this pollen. Nevertheless, there is some controversy about its tolerability. We conducted an open uncontrolled study to evaluate the tolerability of an aluminium adsorbed P. judaica pollen extract whose major allergen (Par j 1) content was known. Changes in immunological parameters to a complete P. judaica extract and to a purified Par j 1 preparation were monitored. Twenty-one patients (12 women, 9 men; mean age 30.2 years) suffering from rhinoconjunctivitis and/or asthma due to Parietaria pollen were enrolled. The maximum dose was established at 10 BU/ml (0.6 microgram Par j 1). Skin and conjunctival reactivity as well as serum levels of specific IgE, IgG, IgG1 and IgG4 were evaluated before therapy (T0), when 1 BU was given (T1), 2 weeks after the maintenance dose was reached (T2) and after the pollen season (T3). Four-hundred and fifteen doses were administered during immunotherapy. Only one systemic reaction (0.24% of doses) and two local reactions were registered. Reactions occurred during the administration of the highest concentrated vial. Before immunotherapy, purified Par j 1 accounted for 94.2% of the cutaneous response elicited by the complete extract. A statistically significant decrease in cutaneous response was detected after 8 weeks of treatment. There were no significant changes in conjunctival reactivity throughout the study. Specific IgG, IgG1 and IgG4 showed a pronounced and significant increase during the study, while specific IgE levels initially decreased and increased after the pollen season. The kinetics of specific antibodies to P. judaica complete extract and purified Par j 1 showed a parallel trend. The present study demonstrates that immunotherapy with P. judaica extract is well tolerated in patients suffering from rhinoconjunctivitis and/or asthma due to Parietaria pollen. This therapy induces specific changes in the immunological response to P. judaica and to purified Par j 1. These changes can be detected at very early stages of therapy.

[Preliminary results of horizontal gastroplasty with Roux in Y anastomosis in patients with severe and morbid obesity]

BACKGROUND

Morbidly obese subjects have a high incidence of complications. The poor results of dietary treatments, has prompted the search of new therapies for obesity and among these, surgical procedures.

AIM

To report the long term results of horizontal gastroplasty with Roux en Y anastomosis in morbidly obese subjects.

PATIENTS AND METHODS

Fifty patients with an initial body mass index of 41.3 +/- 6 kg/m2 have been subjected to a horizontal gastroplasty with Roux en Y anastomosis. During the study period, surgical techniques were modified, reducing the gastric pouch size, adding a truncal vagotomy, cholecystectomy, and increasing the length of the Roux en Y loop from 70 to 100 cm. Twenty five patients have been followed for two years.

RESULTS

There was no operative mortality and one patient had an anastomotic leak that required 35 days of hospitalization. During follow up, in one patient, the stapled suture line loosened. After two years of follow up, weight decreased from 112 +/- 19 to 77.2 +/- 14 kg.

CONCLUSIONS

Horizontal gastroplasty with Roux en Y anastomosis achieved an adequate weight loss with a low rate of complications in this group of morbidly obese subjects.

Role of the Trichoderma harzianum endochitinase gene, ech42, in mycoparasitism

The role of the Trichoderma harzianum endochitinase (Ech42) in mycoparasitism was studied by genetically manipulating the gene that encodes Ech42, ech42. We constructed several transgenic T. harzianum strains carrying multiple copies of ech42 and the corresponding gene disruptants. The level of extracellular endochitinase activity when T. harzianum was grown under inducing conditions increased up to 42-fold in multicopy strains as compared with the wild type, whereas gene disruptants exhibited practically no activity. The densities of chitin labeling of Rhizoctonia solani cell walls, after interactions with gene disruptants were not statistically significantly different than the density of chitin labeling after interactions with the wild type. Finally, no major differences in the efficacies of the strains generated as biocontrol agents against R. solani or Sclerotium rolfsii were observed in greenhouse experiments.

The expression of genes involved in parasitism by Trichoderma harzianum is triggered by a diffusible factor

The mycoparasite Trichoderma harzianum has been extensively used in the biocontrol of a wide range of phytopathogenic fungi. Hydrolytic enzymes secreted by the parasite have been directly implicated in the lysis of the host. Dual cultures of Trichoderma and a host, with and without contact, were used as means to study the mycoparasitic response in Trichoderma. Northern analysis showed high-level expression of genes encoding a proteinase (prb1) and an endochitinase (ech42) in dual cultures even if contact with the host was prevented by using cellophane membranes. Neither gene was induced during the interaction of Trichoderma with lectin-coated nylon fibres, which are known to induce hyphal coiling and appressorium formation. Thus, the signal involved in triggering the production of these hydrolytic enzymes by T. harzianum during the parasitic response is independent of the recognition mediated by this lectin-carbohydrate interaction. The results showed that induction of prb1 and ech42 is contact-independent, and a diffusible molecule produced by the host is the signal that triggers expression of both genes in vivo. Furthermore, a molecule that is resistant to heat and protease treatment, obtained from Rhizoctonia solani cell walls induces expression of both genes. Thus, this molecule is involved in the regulation of the expression of hydrolytic enzymes during mycoparasitism by T. harzianum.

[Drug-induced agranulocytosis: clinical study of 19 cases]

Agranulocytosis is one of the most serious side effects to drugs. From January 1991 to June 1996 were diagnosed 19 cases of agranulocytosis associated with drugs at our hospital (incidence rate: 9.4 over million hab. per year). The average age was 62 and 11 cases were women. The drugs most commonly involved were metamizol and ticlopidine. In 15 of the patients fever blew up and 16 presented some infectious location. In 9 of the cases some positive microbiological culture was obtained, gram-negative bacilli being the commonest. G-CSF was used in 13 of the patients, observing a quicker haematological recovery (5.7 days vs 9.1, p = 0.07), though without any difference in mortality, which was of 0%. All this leads to the following conclusions: a high incidence of agranulocytosis in our environment and the important role of metamizol and ticlopidine in its origin.

Cross-clamping of the three hepatic veins in the piggyback technique is a safe and well tolerated procedure

A common stump of the three hepatic veins has always been used to fashion the upper vena cava anastomosis in 205 liver transplantations with the piggyback (PGB) technique performed in our Unit, to avoid outflow problems. The aim was to study the repercussion of lateral inferior vena cava (IVC) clamping on IVC flow and pressure as well as on systemic hemodynamics. We have studied 42 orthotopic liver transplantations performed with the PGB technique. Intraoperative IVC blood flow measurements by transit time ultrasonic volume flowmetry, IVC pressure, and systemic hemodynamics were taken before and after lateral IVC clamping. Graft outflow complications, stenosis or kinking of the upper vena cava anastomosis have not been found in any of the 205 PGB procedures. A significant decrease of IVC flow (23%) and cardiac output (12%) occurred after IVC clamping, whereas mean arterial and central venous pressures were not altered significantly, probably due to an increase (25%) of systemic vascular resistance. Only in one case was an almost total clamping of IVC needed. Venovenous bypass was not needed in any case. Renal perfusion pressure was adequate in all cases. We conclude that the use of a common stump of the three hepatic veins for upper vena cava anastomosis in the PGB technique is safe because any outflow problem of the graft is avoided and, at the same time, is well tolerated hemodynamically because most of the IVC flow is preserved.

[Clinical and laboratory characteristics of patients with pathologic chronic gastroesophageal reflux]

BACKGROUND

Sixty percent of adults has typical symptoms of gastroesophageal reflux in Chile.

AIM

To report the clinical and laboratory features of patients with gastroesophageal reflux.

PATIENTS AND METHODS

Five hundred thirty-four patients (255 male) with gastroesophageal reflux were included in a prospective protocol that included clinical analysis, manometry and endoscopy in all patients, barium swallow in 427, scintigraphy in 195, acid reflux test in 359, 24 h pH in 175, and differential potential of gastroesophageal mucosa in 73 patients.

RESULTS

There was no correlation between the severity of symptoms and the endoscopical severity. Patients with Barret esophagus were 12 years older, were male in a greater proportion and had a higher proportion of manometrically incompetent sphincters than patients with esophageal reflux but without esophagitis or with erosive esophagitis. Severity of acid reflux, measured with 24 h pH monitoring was proportional to the endoscopical damage of the mucosa. There was a close relationship between the mucosal change limit determined with differential potentials and with endoscopy. No short esophagi were found.

CONCLUSIONS

Patients with symptoms of gastroesophageal reflux must be assessed using several objective measures to determine the severity of their pathological alterations.

[Capacity of weight-for-age and length-for-age to predict stunting at 3 years of age]

OBJECTIVE

To compare the capacity of two cut-off points of weight-for-age and length-for-age (-1 and -2 standard deviations) at different ages in the interval between birth and 30 months to predict stunting in three year old children.

MATERIAL AND METHODS

Data from a longitudinal study in Guatemala were used to evaluate the hypothesis that the capacity of cut-off values of weight-for-age and length-for-age to predict stunting at three years of age varies according to age.

RESULTS

Length-for-age at -1 standard deviation (SD) of the WHO/NCHS mean reference values is a satisfactory prognostic indicator of stunting at three years of age during the first semester of life, while the same index at -2 SD is adequate after 9 months of age. Weight-for-age at -1 SD is a suitable indicator only at 9 months and at -2 SD the indicator is satisfactory between 15 and 24 months of age.

CONCLUSION

The capacity to predict stunting at three years of age, for weight-for-age and length-for-age cut-off values varies according to age.

[Energy and nutrient consumption in Mexican women in reproductive age]

OBJECTIVE

To analyze energy and nutrient consumption in Mexican women from 12 to 49 years of age.

MATERIAL AND METHODS

Dietetic information was gathered by a 24 h recall from 9,101 women who participated in the National Nutrition Survey conducted in 1988. These data were compared with sociodemographic and physiologic characteristics. Nutrient consumption was compared with the Recommended Daily Allowances (RDA). Variance analysis and t-test were used to evaluate group differences.

RESULTS

Mean energy consumption was 1,721 kcal per day. The diet consisted of 15% protein, 60% carbohydrates and 25% fat. The proportion of women with dietary intakes lower than 50% of the RDA was 70% for vitamin A, 75% for vitamin B6, 56% for vitamin C, 33% for vitamin B12, 69% for folate, 33% for calcium and 22% for iron.

CONCLUSION

Results show important deficiencies in the diet, predominantly in pregnant and lactating women, in women from low socioeconomic levels and in rural and indigenous women of south of the Mexican republic.

Field evaluation of a diagnostic protocol for Chagas' disease and rangeliosis

The present paper evaluates the protocol for the diagnosis of Chagas' diseases and rangeliosis that is suitable for use in remote and scarcely populated rural areas. Beginning with a blood sample taken by venipuncture in the rural dispensary from 350 inhabitants of Caserío La Sierra, Cojedes State, Venezuela, samples were analyzed at a laboratory located at a distance of 150 Km. Each blood sample was analyzed for blood and clot culture, artificial xenodiagnosis, inoculation into mice, complement fixation reaction (CFR), and indirect fluorescent antibodies test (IFA). Nine isolates of trypanosomes were obtained and identified as Trypanosoma rangeli, 29.4% of the blood samples showed seropositivity for Trypanosoma cruzi, 7.1% of total of persons between 6 and 18 years were found infected with T. rangeli, suggesting active transmission of this trypanosome in an endemic area for Chagas' disease. Results indicate that this protocol of study is reliable, economical and sufficiently versatile to study both rangeliosis and Chagas' disease.

Indoor allergens and dwelling characteristics in two cities in Spain

BACKGROUND

Indoor allergens are common causes of sensitization and asthma. Climatic and home conditions can modify their levels.

OBJECTIVE

We studied the influence of climatic conditions and home characteristics on the exposure to indoor allergens of mite allergic asthmatic subjects in two Spanish cities with different climates (Las Palmas and Pamplona).

METHODS

We included 65 subjects diagnosed with asthma caused by Dermatophagoides pteronyssinus. A questionnaire about their dwellings was completed. Home dust samples were collected. Mite (Der p1, Der f1, Der 2) and cat (Fel d1) allergens were measured by a monoclonal-antibodies based ELISA.

RESULTS

Characteristics of dwellings were similar in both areas. Der p1 was the main allergen (0-44 micrograms/g). Der p1, Der f1 and Der 2 levels were higher in the homes in Las Palmas (p < 0.001, p < 0.01 and p < 0.001, respectively). Damp homes in Pamplona had higher Der p1 levels, similar to those detected in homes in Las Palmas. Fel d1 levels (0-78.90 micrograms/g) were only related to the presence of cats in the dwelling (p < 0.001).

CONCLUSIONS

D. pteronyssinus allergen exposure was influenced by climatic conditions and dampness in homes in temperate regions. Humidity in homes can generate an ideal environment for mite growth despite unfavorable outdoor climatic conditions. Fel d1 levels were only related to the presence of a cat in the house.

Clinical efficacy and tolerance of two year Lolium perenne sublingual immunotherapy

Last years, in spite of increasing use of sublingual immunotherapy (SLIT), not enough clinical studies have been published and its efficacy ought to be documented still more. For that purpose, 54 patients suffering seasonal rhinoconjunctivitis--with or without asthma--were allocated to either six month preseasonal SLIT with Lolium perenne extract (n = 35) or to a control group (n = 19). In the following year, thirty from previously treated patients and 12 from former control group, received a nine-month pre-coseasonal SLIT. Skin (SPT) and conjunctival (CPT) allergen response were monitorized several times along the study. Either seric antibodies or intraseasonal eosinophil cationic protein (ECP), as symptom, medication scores and peak nasal inspiratory flow (PNIF) were also assessed, fifty-five adverse reactions were recorded (0.7% doses), although only four required treatment. No main changes in CPT, SPT and antibodies were detected. Nevertheless, during the first pollen season, treated patients needed less medication than their control counterparts (p < 0.05). In the second season, the twelve ex-control subjects also required fewer drugs than in the first one (p < 0.01). Moreover, the whole forty-two treated patients showed a lesser intraseasonal ECP than a reference set of grass-allergic individuals (p < 0.05). We conclude that Lolium perenne SLIT is well tolerated and induces fewer drug requirements during pollen season, being eosinophil activation additionally reduced.

Recognition of an immunogenetically selected Trypanosoma cruzi antigen by seropositive chagasic human sera

If the H-2 congenic mouse strains A.SW (H-2n) and A.CA (H-2f), are infected with Trypanosoma cruzi, a 45 kDa protein (Tc45), present in cultured epimastigotes and blood trypomastigotes, is recognized only by the A.SW strain sera. In order to explore the possibility that among seropositive humans the response to Tc45 is also highly variable, 81 chagasic human sera (as defined by the HemAve agglutination test, Polychaco S.A.I.C., Buenos Aires, Argentina) were tested in a direct (epimastigote antigenic complex directly bound to the solid phase) and indirect immunoradiometric assay (IRMA) (Tc45, from a partially purified preparation, bound to the solid phase, by means of a monoclonal antibody). Sixty nine of these sera reacted in both the direct and indirect assays, 11 were negative in both assays (these samples may correspond to false positives detected by the commercial agglutination test) and only one reacted with the antigenic complex but not with Tc45. Reactivity of the human sera with the epimastigote antigenic extract was relatively homogenous, while reactivity with Tc45 was extremely variable. No statistical correlation was determined between the two variables. Given the high variability of the human response to Tc45, ranging from negative to highly positive, together with the immunogenetic restriction previously described in the murine model, we speculate that human MHC may also modulate the response to this molecule.

Immunotherapy with standardized extract of Dermatophagoides pteronyssinus in bronchial asthma: a dose-titration study

According to the maximum tolerated dose (MTD) achieved, we assessed the changes in clinical and laboratory parameters, induced by specific immunotherapy (SIT), in a group of 43 asthmatic patients sensitized to Dermatophagoides pteronyssinus, over a period of 18 months. A standardized extract (100 Bu/ml; 40 micrograms/ml of Der p 1; 20 micrograms/ml of Der p 2) was used. The patients were divided into two groups: the high-dose immunotherapy (HDI) group (MTD > or = 4 micrograms Der p I) and the conventional immunotherapy (CI) group (MTD < 4 micrograms Der p 1). Changes in clinical severity index, medication, and symptom scores; in cutaneous and conjunctival reactivity; and in the levels of specific IgE, IgG, IgG1, and IgG4 to D. pteronyssinus (Der p 1 and Der p 2) were measured (ELISA monoclonal antibodies). Safety was monitored according to the EAACI guidelines. The range of the MTD was 0.8-16 micrograms of Der p 1. Ninety percent of the patients tolerated a dose of 3.2 micrograms, but only 18% of the patients reached a maintenance dose of 16 micrograms. The medians of the accumulated dose were 197 micrograms of Der p 1 for the HDI group, and 50 micrograms for the CI group. Conjunctival and cutaneous reactivity was significantly lowered (P < 0.001) after SIT, as were the clinical severity score and medication score in both groups, without significant differences between the groups, except for cutaneous reactivity. Levels of specific IgE decreased significantly (P < 0.01) in both groups, again without significant differences between the groups. The range of the increase in medians of specific IgG, IgG1, and IgG4 was 4.4-120-fold for the HDI group and 3-24-fold for the CI group (P < 0.01). The increase in the levels of Der p 1 and Der p 2 IgG4 were correlated to the changes in cutaneous and conjunctival reactivity (P < 0.01). These results show that a maintenance dose of 3.2 micrograms Der p 1 (8 BU) can induce pronounced clinical and immunologic changes with an excellent safety profile.

A computer program based on parallel line assay for analysis of skin tests

A computer program for the analysis of differences or changes in skin sensitivity has been developed. It is based on parallel line assay, and its main features are its ability to conduct a validation process which ensures that the data from skin tests conform to the conditions imposed by the analysis which is carried out (regression, parallelism, etc.), the estimation of the difference or change in skin sensitivity, and the determination of the 95% and 99% confidence intervals of this estimation. This program is capable of managing data from independent groups, as well as paired data, and it may be applied to the comparison of allergen extracts, with the aim of determining their biologic activity, as well as to the analysis of changes in skin sensitivity appearing as a consequence of treatment such as immunotherapy.