Patterns of infection and infection-related mortality in patients with steroid-refractory acute graft versus host disease

This study aimed to characterize the incidence, etiology and outcome of infectious episodes in patients with steroid refractory acute GvHD (SR-GvHD). The cohort included 127 adults treated with inolimomab (77%) or etanercept (23%) owing to acute 2-4 SR-GvHD, with a response rate of 43% on day +30 and a 4-year survival of 15%. The 1-year cumulative incidences of bacterial, CMV and invasive fungal infection were 74%, 65% and 14%, respectively. A high rate (37%) of enterococcal infections was observed. Twenty patients (15.7%) developed BK virus-hemorrhagic cystitis and five percent had an EBV reactivation with only one case of PTLD. One-third of long-term survivors developed pneumonia by a community respiratory virus and/or encapsulated bacteria, mostly associated with chronic GvHD. Infections were an important cause of non-relapse mortality, with a 4-year incidence of 46%. In multivariate analysis, use of rituximab in the 6 months before SCT (hazard ratio; HR 4.2; 95% confidence interval; CI 1.1-16.3), severe infection before SR-GvHD onset (HR 5.8; 95% CI 1.3-26.3) and a baseline C-reactive protein >15 UI/mL (HR 2.9; 95% CI 1.1-8.5) were associated with infection-related mortality. High rates of opportunistic infections with remarkable mortality warrant further efforts to optimize long-term outcomes after SR-GvHD.

Biodiesel production from crude Jatropha oil catalyzed by non-commercial immobilized heterologous Rhizopus oryzae and Carica papaya lipases

The aim of this study was to evaluate the feasibility of biodiesel production by transesterification of Jatropha oil with methanol, catalyzed by non-commercial sn-1,3-regioselective lipases. Using these lipases, fatty acid methyl esters (FAME) and monoacylglycerols are produced, avoiding the formation of glycerol as byproduct. Heterologous Rhizopus oryzae lipase (rROL) immobilized on different synthetic resins and Carica papaya lipase (rCPL) immobilized on Lewatit VP OC 1600 were tested. Reactions were performed at 30°C, with seven stepwise methanol additions. For all biocatalysts, 51-65% FAME (theoretical maximum=67%, w/w) was obtained after 4h transesterification. Stability tests were performed in 8 or 10 successive 4h-batches, either with or without rehydration of the biocatalyst between each two consecutive batches. Activity loss was much faster when biocatalysts were rehydrated. For rROL, half-life times varied from 16 to 579h. rROL on Lewatit VPOC 1600 was more stable than for rCPL on the same support.

Molecular evidence of type 2 mosaicism in Gorlin syndrome

We present a 12-year-old girl with a family history of Gorlin syndrome who had unilateral, segmentally arranged basaloid skin tumours present since birth, ipsilateral, palmoplantar pits of rather large size distributed along Blaschko lines, and an ipsilateral odontogenic keratocyst. The patient and her father were heterozygous for a germline mutation in the form of a single-base substitution in exon 18 of the PTCH1 gene. In the patient's lesional skin, a microdeletion in exon 3 of PTCH1 was detected, giving rise to a truncated protein. This additional mutation was ruled out in the contralateral skin and in blood lymphocytes, thus confirming its mosaic state. In this way we provide for the first time molecular proof of a type 2 segmental involvement of this autosomal dominant trait.

Cellular hypomethylation is associated with impaired nitric oxide production by cultured human endothelial cells

Hyperhomocysteinemia (HHcy) is a risk factor for vascular disease, but the underlying mechanisms remain incompletely defined. Reduced bioavailability of nitric oxide (NO) is a principal manifestation of underlying endothelial dysfunction, which is an initial event in vascular disease. Inhibition of cellular methylation reactions by S-adenosylhomocysteine (AdoHcy), which accumulates during HHcy, has been suggested to contribute to vascular dysfunction. However, thus far, the effect of intracellular AdoHcy accumulation on NO bioavailability has not yet been fully substantiated by experimental evidence. The present study was carried out to evaluate whether disturbances in cellular methylation status affect NO production by cultured human endothelial cells. Here, we show that a hypomethylating environment, induced by the accumulation of AdoHcy, impairs NO production. Consistent with this finding, we observed decreased eNOS expression and activity, but, by contrast, enhanced NOS3 transcription. Taken together, our data support the existence of regulatory post-transcriptional mechanisms modulated by cellular methylation potential leading to impaired NO production by cultured human endothelial cells. As such, our conclusions may have implications for the HHcy-mediated reductions in NO bioavailability and endothelial dysfunction.

Uncoupling oxidative/energy metabolism with low sub chronic doses of 3-nitropropionic acid or iodoacetate in vivo produces striatal cell damage

A variety of evidence suggests that the failure of cellular metabolism is one of the underlying causes of neurodegenerative diseases. For example, the inhibition of mitochondrial function produces a pattern of cellular pathology in the striatum that resembles that seen in Huntington's disease. However, neurons can also generate ATP through the glycolytic pathway. Recent work has suggested a direct interaction between mutated huntingtin and a key enzyme in the glycolytic pathway, glyceraldehyde-3-phosphate dehydrogenase (GAPDH). Yet little work has been gone into examination of the cellular pathology that results from the inhibition of this alternative energy source. Therefore, the aim of the present study is to characterize the cellular pathology that results in the striatum of mice after treatment with a toxin (iodoacete, IOA) that compromises anaerobic metabolism. This striatal pathology is compared to that produced by a widely studied blocker of mitochondrial function (3-nitropropionic acid, 3-NP). We found that low doses of either toxin resulted in significant pathology in the mouse striatum. Signs of apoptosis were observed in both experimental groups, although apoptosis triggered by IOA treatment was independent from caspase-3 activation. Importantly, each toxin appears to produce cellular damage through distinct mechanisms; only 3-NP generated clear evidence of oxidative stress as well as inhibition of endogenous antioxidants. Understanding the distinct pathological fingerprints of cell loss produced by blockade of oxidative and anaerobic metabolisms may give us insights into neurodegenerative diseases.

Association of A313 G polymorphism (GSTP1*B) in the glutathione-S-transferase P1 gene with sporadic Parkinson's disease

Genetic predisposition, environmental toxins and aging contribute to Parkinson's disease (PD) multifactorial etiology. Weak environmental neurotoxic factors may accumulate over time increasing the disease risk in genetically predisposed subjects. Polymorphic genes encoding drug-metabolizing-enzymes (DMEs) are considered to account for PD susceptibility by determining individual toxic response variability. In this work, the allelic distributions and genotype associations of three major brain-expressed DMEs were characterized, in sporadic PD cases and controls. No significant association was found between CYP2D6 genotype and PD, but subjects with extensive metabolizer (EM) CYP2D6 phenotype, and the variant GSTP1*B genotype were at significantly higher PD risk than the corresponding poor or intermediary metabolizers (CYP2D6 poor metabolizer phenotype+intermediary metabolizers). A significant association was observed between the GSTP1*B allele and zygosity with PD (GSTP1*A/*B- 51.58%/34.37%, odds ratio (OR) = 2.29; 95% confidence interval (95% CI) = 1.25-4.18; *B/*B- 6.32%/1.05%, OR = 10.67; 95% CI = 1.19-94.79). This association was particularly strong in the elder patients group (> or =69 year) who showed double PD risk for GSTP1*B heterozygous, whilst GSTP1*B/*B homozygous were exclusively found amongst patients. An interaction between GSTM1 and GSTP1 was observed in this late onset PD group. The present results suggest that native GSTP1 encoding the fully active transferase variant should play a relevant role in dopaminergic neuroprotection.

Mutational spectrum of classical galactosaemia in Spain and Portugal

Classical galactosaemia is an autosomal recessive inherited metabolic disorder due to deficient galactose-1-phosphate uridyltransferase (GALT). Over 180 different base changes and disease-causing mutations have been reported in the GALT gene. Mutation p.Q188R was found to be the most common molecular defect among caucasian classical galactosaemia patients. We have characterized the spectrum of GALT mutations in a group of 51 Spanish families and 32 Portuguese families with this disease. p.Q188R is also the most prevalent mutation in the Spanish and Portuguese population, accounting for 50% and 57.8% of galactosaemic alleles, respectively. An additional 15 mutations were also identified in Spanish patients, four of which were novel: p.D28H, p.S181A, c.658dupG and c.377+53_1059+87del. In the Portuguese population, 11 different mutations were found, three of which were novel: p.R33H, p.P185S, and p.S192G. The differences observed between the genotypes identified in Portuguese and Spanish galactosaemic populations are notable. Only mutations p.Q188R, p.R148Q and c.820+13g>a were identified in both populations. In spite of the geographical proximity of Spain and Portugal, it seems that they have received genetic influences from different populations. The repeated migrations that occurred in the Iberian Peninsula throughout centuries may explain such variability.

Homocysteine metabolism, hyperhomocysteinaemia and vascular disease: an overview

Hyperhomocysteinaemia has been regarded as a new modifiable risk factor for atherosclerosis and vascular disease. Homocysteine is a branch-point intermediate of methionine metabolism, which can be further metabolised via two alternative pathways: degraded irreversibly through the transsulphuration pathway or remethylated to methionine by the remethylation pathway. Both pathways are B-vitamin-dependent. Plasma homocysteine concentrations are determined by nongenetic and genetic factors. The metabolism of homocysteine, the role of B vitamins and the contribution of nongenetic and genetic determinants of homocysteine concentrations are reviewed. The mechanisms whereby homocysteine causes endothelial damage and vascular disease are not fully understood. Recently, a link has been postulated between homocysteine, or its intermediates, and an alterated DNA methylation pattern. The involvement of epigenetic mechanisms in the context of homocysteine and atherosclerosis, due to inhibition of transmethylation reactions, is briefly overviewed.

ompU genes in non-toxigenic Vibrio cholerae associated with aquaculture

AIMS

The study was undertaken with the objective of understanding the virulence-associated genes of the CTX and TCP gene clusters in environmental isolates of Vibrio cholerae, an important human pathogen, isolated from the aquaculture environment. The involvement of the ompU gene in conferring bile resistance in these isolates was also evaluated.

METHODS AND RESULTS

The V. cholerae isolates were tested by PCR and fluorescent antibody test for O1 (Ogawa and Inaba) and O139 serotypes. All isolates were found to be non-toxigenic V. cholerae confirmed by their positive PCR reaction for toxR but negative for ctx, zot and tcp gene. The hlyA gene was detected in 85% of the strains and ompU in 77%. The results on the bactericidal effect of bile salts suggest that ompU may play a role in conferring bile resistance in non-O1/non-O139 strains.

CONCLUSION

The results of the study indicate that most environmental strains lacked the CTX and TCP gene clusters. However, most isolates had the hlyA gene indicating the potential of these environmental strains to cause mild gastroenteritis. It was also observed that strains lacking ompU showed less tolerance to bile salts.

SIGNIFICANCE AND IMPACT OF THE STUDY

Information on virulence factors of V. cholerae associated with aquaculture environment and products would be of value in risk assessment for human health.

5,10-Methylenetetrahydrofolate reductase 677C-->T and 1298A-->C mutations are genetic determinants of elevated homocysteine

BACKGROUND

Methylenetetrahydrofolate reductase (MTHFR) is one of the main regulatory enzymes of homocysteine metabolism. Elevated plasma total homocysteine (tHcy) is a major risk for cardiovascular disease. A common 677C-->T mutation in the MTHFR gene results in decreased enzymic activity, and contributes to increased plasma tHcy, in association with low plasma folate. A recently described 1298A-->C mutation in the MTHFR gene clearly reduces MTHFR activity (although to a lesser extent than the 677C-->T) but its effect on plasma tHcy levels is not yet clear.

AIM

To investigate the frequency of these two MTHFR polymorphisms in a Portuguese population, and to correlate the MTHFR genotype with the biochemical phenotype at the level of homocysteine and folate concentrations.

DESIGN

Prospective population survey.

METHODS

We studied 117 healthy volunteers (71 females, 46 males). The 677C-->T and 1298A-->C mutations were screened by PCR-RFLP. Levels of plasma tHcy and folate, and red blood cell folate, were determined.

RESULTS

The allele frequencies of the 677C-->T and 1298A-->C mutations were 0.33 and 0.28, respectively. Homozygotes for the 677C-->T mutation had significantly elevated plasma tHcy and RBC folate levels and significantly lowered plasma folate concentrations than subjects without the mutation. The 1298A-->C mutation showed a significant effect on plasma tHcy, but not on plasma folate or RBC folate levels.

DISCUSSION

The observed 677T allele frequency is not consistent with the idea of a north-south gradient as previously suggested. The 1298A-->C mutation is common in Portugal. Both MTHFR mutations showed effects on plasma tHcy levels.

Sleep pattern and daytime differences in the electromyographic activity and peripheral temperature

For a long time, it has been said that most individuals sleep an average of 8 h. However, there are subjects that usually sleep less than 6 h (the ones placed under the label of short sleep pattern, SSP) and subjects that sleep more than 8 h (those classified by the long sleep pattern, LSP). Starting from this division, several studies have been carried out in order to establish possible differences in terms of psychological and physiological variables. This study is aimed at assessing the differences that might occur in electromyographic activity and temperature in long, medium and short sleep pattern subjects at two moments in the day. From a 300-subject sample, 17 long sleep pattern, nine medium sleep pattern and eight short sleep pattern subjects were selected. The physiological variables were assessed during a constant stimulation task in the morning (between 09.00 and 10.00 h) and in the evening (between 19.00 and 20.00 h). The inter-group analysis showed that the long sleep pattern and the short sleep pattern subjects differed in terms of electromyographic activity in the morning. This same analysis indicated that only long sleep pattern subjects showed changes in electromyographic activity over two measurements taken in the same day. The results point out that long sleep pattern subjects show more sensitivity towards changes, and that sensitivity is expressed in a different manner, depending on the time of the day.

Mutation analysis of the GCDH gene in Italian and Portuguese patients with glutaric aciduria type I

Two novel (G390V and X439W) and five already known mutations were identified in a total of 14 GA I alleles from Italy and Portugal. The substitution X439W is a rare type of mutation, which breaks the stop codon of the GCDH gene. As described in other populations, R402W was the most common mutation. Genotype R227P/R402W was found in a patient with low glutarate excretion. Haplotype studies have also been performed.

Simple cystectomy in patients requiring urinary diversion

PURPOSE

Urinary diversion is an alternative treatment for conditions such as radiation and interstitial cystitis, neurogenic bladder and severe incontinence. The subsequent complication rate may reach 60% due to the retained nonfunctional bladder. The subsequent cystectomy rate may be as high as 20% because of pyocystis, hematuria, pelvic pain and rarely bladder cancer. We describe simple cystectomy involving bladder removal without the adjacent structures, avoiding deep pelvic dissection.

MATERIALS AND METHODS

Ileal conduit or continent diversion and simple cystectomy were performed for crippling bladder symptoms secondary to neurogenic bladder, pelvic radiation, hematuria and/or severe incontinence in 12 women and 7 men with a mean age of 63 years. We performed urinary diversion and simple cystectomy only when all conservative means of treatment had failed. The majority of patients had multiple co-morbidities, previous surgeries and pelvic radiation. An average of 5 conservative procedures (range 2 to 10) had been done before simple cystectomy. None of these patients had urothelial malignancy. Simple cystectomy was done concomitantly with urinary diversion in 13 cases and later as a separate procedure in 6 due to complications of a retained nonfunctional bladder.

RESULTS

Mean followup was 15 months. No mortality was associated with surgery. For simple cystectomy only mean operative time was 30 minutes and mean estimated blood loss was 300 cc. Median time from symptom presentation to cystectomy was 35 months and mean hospital stay was 7 days. In all cases symptoms were dramatically alleviated. No morbidity was directly attributable to simple cystectomy.

CONCLUSIONS

Simple cystectomy is well tolerated and should be performed at urinary diversion to avoid later complications of the retained bladder. Technically this procedure is not demanding and is relatively easy to perform even after previous pelvic radiation.

Bladder-sparing treatment of invasive bladder cancer

BACKGROUND

Radical cystectomy with pelvic lymph node dissection is the standard treatment for patients with invasive bladder cancer. However, many alternative techniques to spare the bladder have been investigated.

METHODS

We review the experience reported in the literature on bladder-sparing techniques, including transurethral resection, chemotherapy, and radiation for muscle-invasive disease.

RESULTS

Most comparative studies indicate that local recurrence and survival outcomes for bladder-sparing approaches are inferior to those from radical cystectomy to control muscle-invasive bladder cancer.

CONCLUSIONS

Although molecular biologic techniques may have the capacity to identify a subgroup who may benefit from a bladder-sparing approach, cystectomy is normally required for optimal results.

Threshold and retreatment parameters of NPe6 photodynamic therapy in retinal and choroidal vessels

BACKGROUND AND OBJECTIVE

To determine the threshold fluence for producing choroidal and retinal vascular occlusion with mono-L-aspartyl chlorin e6 (NPe6) photodynamic therapy (PDT) during primary treatment and the effect of retreatment.

METHODS

Primary treatment: Rats, rabbits, and monkeys underwent NPe6 PDT to determine the threshold fluences for choroidal and retinal vessel occlusion. The threshold was determined by analyzing fluorescein angiograms for areas of nonperfusion. Retreatment: Dutch-belted rabbits underwent NPe6 PDT followed by fluorescein angiography. Rabbits were retreated one week later at the same parameters.

RESULTS

Fluence levels and vascular damage thresholds were always higher for retinal than for choroidal vascular occlusion. Retreatment caused choroidal vessel closure at all tested fluences but retinal capillaries closed only at a fluence > 17.7 J/cm2.

CONCLUSION

NPe6 PDT has a lower threshold to occlude choroidal vessels than retinal vessels. The cumulative effect of retreatment does not damage retinal vessels unless the threshold is exceeded during a single retreatment session.

The correlation of genotype and phenotype in Portuguese hyperphenylalaninemic patients

To understand the basis for the clinical heterogeneity of phenylalanine hydroxylase deficiency among Portuguese hyperphenylalaninemic patients, genotype-phenotype correlations were established. A group of 61 patients was completely genotyped, leading to the identification of 20 different mutant alleles in 36 different genotypic combinations, including a mutant allele not reported previously. The severity of those mutations found within this hyperphenylalaninemic population, which have not been previously expressed in vitro, were assessed. The results obtained by the present study exhibit a strong correlation between the predicted residual enzyme activity, as deduced from the genotype of the patients, and the biochemical phenotype represented by the diagnostic parameters (phenylalanine levels before the beginning of treatment and the dietary phenylalanine tolerance). It was observed that only a judicious follow-up and compliance with the appropriate diet permits the correct assessment of the clinical phenotype of the patients. Additionally, based upon the correlation observed between genotypes and diagnostic parameters, it was possible to predict the potential residual enzyme activity of those mutations (identified in our patients) which have not yet been studied in vitro.

The V388M mutation results in a kinetic variant form of phenylalanine hydroxylase

The molecular mechanism underlying the metabolic defect in phenylketonuria (PKU) patients carrying the V388M missense mutation of the phenylalanine hydroxylase (PAH) gene has been characterized. An in vitro prokaryotic expression system has been used to produce both the wild-type and the mutant form of the human PAH (hPAH) protein. The recombinant enzymes, obtained as fusion proteins, were purified by immobilized metal affinity chromatography and recovered in high yields. The wild-type hPAH possessed a high specific activity and its kinetic properties were the same as those reported for the enzyme isolated from human liver and other recombinant wild-type hPAH enzymes. The recombinant V388M mutant form exhibited a reduced specific activity equivalent to 30% of the wild-type hPAH enzyme when assayed using the synthetic cofactor (6-methyltetrahydropterin). Lower values were obtained (23 and 19%) when the mutant enzyme was assayed with the natural cofactor ((6R)-tetrahydrobiopterin) and different concentrations of l-phenylalanine. The enzyme kinetic studies of the V388M mutant protein revealed that this enzyme was a kinetic variant form of hPAH with a reduced affinity for l-phenylalanine and for the natural cofactor ((6R)-tetrahydrobiopterin). The residual activities determined for the V388M form of hPAH were compatible with the phenotype presented by the PKU patients harboring the V388M mutation in the PAH gene.

Involvement of NF-AT in type I human T-cell leukemia virus Tax-mediated Fas ligand promoter transactivation

Human T-cell leukemia virus type I (HTLV-I)-infected T-cells constitutively express surface Fas ligand (FasL), which may serve as a mechanism of viral pathogenesis. HTLV-I induces transcription of FasL gene through the viral transactivator Tax, although the underlying molecular mechanism remains unclear. In the present study, we have analyzed both the cis-activating element and transactivating factors involved in Tax activation of the FasL promoter. We show that the 486-base pair upstream region of the human FasL gene is sufficient for Tax-mediated transactivation in Jurkat T-cells. Interestingly, a palindromic DNA sequence (GGAAACTTCC) covering the consensus NF-ATp binding site (GGAAA), is required for Tax activation of FasL promoter. The involvement of NF-AT in this transactivation event is suggested by the finding that Tax fails to activate the FasL promoter in a Jurkat T-cell line defective in capacitative calcium entry, a signaling mechanism involved in NF-AT activation. Furthermore, activation of FasL promoter by Tax is largely attenuated in the nonlymphoid F9 embryonal and COS kidney cells deficient in NF-ATp expression. DNA-protein interaction assays reveal that the NF-AT-like motif in the FasL promoter is bound by both NF-ATp and NF-AT4 in Jurkat T-cells expressing Tax. The binding of NF-ATp, although not NF-AT4, to this enhancer also occurs along with HTLV-I-mediated infection of human peripheral blood T-cells. Furthermore, exogenously transfected NF-ATp binds to the NF-AT-like enhancer and participates in Tax-mediated FasL promoter transactivation. These results suggest an important role for proteins of the NF-AT family in HTLV-I Tax-mediated FasL gene transactivation.

Population genetics of hyperphenylalaninaemia resulting from phenylalanine hydroxylase deficiency in Portugal

In order to elucidate the molecular basis of phenylketonuria (PKU) in Portugal, a detailed study of the Portuguese mutant phenylalanine hydroxylase (PAH) genes was performed. A total of 222 mutant alleles from 111 PKU families were analysed for 26 mutations and restriction fragment length polymorphismlvariable number tandem repeat (RFLP/VNTR) haplotypes. It was possible to characterise 55% of the mutant alleles, in which 14 different mutations (R261Q, V388M, IVS10nt-11, I65T, P281L, R252W, R158Q, L348V, Y414C, L311P, Y198fsdel22bp, R408W, R270K, and R261X) and three polymorphisms (Q232Q, V245V, and L385L) were identified. A total of 14 different haplotypes were observed, with a high prevalence of haplotype 1 among mutant and normal alleles. The results reported in this study show considerable genetic heterogeneity in the Portuguese PKU population, as has also been described for other southern European populations.

Assessment using ELISA of the herd immunity levels induced in cattle by foot-and-mouth disease oil vaccines

The development of a liquid-phase blocking sandwich ELISA (LPBE) to measure antibodies (Ab) produced in cattle with the O, A and C foot-and-mouth disease virus (FMDV) types of commercial vaccines used in Argentina is described. The test was specific: 99% of naïve cattle sera (n = 130) gave titres below log10 = 1.2, and none had a titre above log10 = 1.5. Comparative studies with serum neutralization test (SNT) using sera from cattle which received one or more vaccine doses is reported. The overall rank correlation coefficient (Spearman's rho, rs) between SNT and LPBE were highly significant (rs > 0.67, P < 0.0001) for all vaccine strains. LBPE Ab titres on sera collected 90 days post vaccination were compared with results of cattle protection tests by applying a logistic regression. The minimum Ab titres at which 85% and 75% of the cattle were protected for each FMDV type were determined in order to interpret field Ab data in terms of protection. Application of this method allows large scale serological examinations to monitor antibody levels in vaccinated animals as an indirect indicator of the FMD control program status in the field. Its use in the evaluation of commercial batches of FMD vaccine is discussed.

[The risk factors in primary bacteremias: a case-control study]

Nosocomial bacteremias are a important cause of mobility and mortality for hospitalized patients which, in addition, generate additional and elevated costs to the institutions. Its frequency has increased in the last year in relation to a greater number of patients, many of them immunosuppressed, which are submitted to invasive procedures. In this study, we analyzed the primary nosocomial bacteremias which occurred in our institution, carrying out a comparative case and control study in order to find the main risk factors which condition their occurrence. In a period of 42 months, 83 episodes of nosocomial primary bacteremias were detected. These represented an incidence of 8 per 1000 of patients which left the hospital and with a clear rising incidence in the last six months. In the Intensive Care Unit (ICU) a greater rate was found per sector (21.3 x 1000). The predominating agents were S. epidermidis, enterobacteremia, S. aureus and enteroccocci. Of the 15 possible risk factors analyzed by multiple regression, those significant were over two weeks of hospital stay and the use of parenteral feeding. These results make it imperative to reinforce control measures in the preparation of parental feeding solutions as in patients with prolonged hospital stay, especially in the ICU.

[Oral pathology in 161 asymptomatic and symptomatic HIV-positive patients]

The aim of this study was to establish the prevalence of oral manifestations in HIV-infected patients and to correlate their frequency with the clinical stage. One hundred and sixty one HIV-positive individuals were examined, of whom 64 (40%) were in stages CDC-II and III and 97 (60%) in stage CDC-IV. The patients were examined at the AIDS out-patient clinic of the Instituto Nacional de la Nutrición Salvador Zubirán. The oral exams were performed by three examiners who were intra and inter calibrated, so that standard clinical criteria were followed. One hundred and twenty five patients (78%) showed one or more oral lesions. The proportion of patients with oral lesions increased significantly (p less than 0.05) according to the severity of the infection. Hairy leukoplakia (40%) and erythematous candidiasis (31%) were the most frequent lesions. When the prevalence of the different oral lesions was compared between the patients at early stages with the patients at the late stage no significant differences were found; only the pseudomembranous candidiasis and the exfoliative cheilitis were found with significantly higher values at stage CDC-IV than at earlier stages (p less than 0.001 and p less than 0.05 respectively). No association was found between oral candidiasis and tobacco use or xerostomia. Our study demonstrates that the prevalence and clinical features of the oral manifestations found showed similarities with those reported in other countries, but ulcero-necrotizing gingivitis was not found in our patients.

Oral lesions in Mexican HIV-infected patients

One hundred and twenty-five HIV-infected patients, of whom 49 (39%) were at early stages of the infection (CDC-II & III) and 76 (61%) in CDC IV, were prospectively examined. In 100 (80%) one or more oral mucosal lesions were observed; candidiasis (51%) and hairy leukoplakia (43%) were the commonest. Erythematous candidiasis was more often seen (35%) than the pseudomembranous type (16%), and appeared with the higher values at early than later stages. The prevalence of hairy leukoplakia, oral hyperpigmentation and xerostomia were incremented in groups CDC-IV. Pseudomembranous candidiasis and exfoliative cheilitis increased significantly with severity of disease. Our study demonstrates that oral alterations associated to HIV are a frequent finding, both at early (76%) and late (83%) stages of the infection in Mexican patients.

[Successful fibrinolytic treatment in a patient with acute mitral prosthetic thrombosis]

A case is described of a 50 year-old man with an acute prosthetic dysfunction due to valve thrombosis and cardiogenic shock, on a prosthesis in the mitral position (Bjork-Shiley). The patient was promptly treated with a streptokinase in two infusions 1.5 x 10(6) UI over 180 and 90 minutes, respectively. Early clinical, fluoroscopy and echocardiography improvement was observed. The authors comment the present role of the thrombolytic therapy in front of surgery of prosthetic valve thrombosis.

[Pericardiocentesis: usefulness in the routine determination of intrapericardial pressure]

The usefulness of routine intrapericardial pressure determination and hemodynamic monitoring during therapeutic (n = 22) or diagnostic (n = 2) pericardiocentesis was analyzed. Hemodynamic data confirmed the presence of cardiac tamponade in all cases, including the 2 patients without clinical suspicion. Prior to fluid evacuation, abnormally elevated levels of intrapericardial (13 +/- 5 mmHg), right atrial (14 +/- 4 mmHg) and pulmonary capillary (16 +/- 3 mmHg) pressures were observed. A significant correlation was found between intrapericardial and right atrial pressures (r = 0.97, p less than 0.05) and also between intrapericardial and pulmonary capillary pressures (r = 0.69, p less than 0.05). The basal cardiac output was low (3 +/- 1 l/min) and increased after the pericardiocentesis in all but one patient. According to the results of pericardiocentesis, patients were classified into three groups. Group I: intrapericardial and right atrial pressures decreased to normal levels. The increment of cardiac output was high (72%) and the procedure was considered successful. Group II: right atrial and intrapericardial pressures remained elevated (7.7 +/- 4 and 7 +/- 2 mmHg, respectively) and the cardiac output increment was less marked (52%), thus indicating incomplete drainage. Group III: intrapericardial pressure decreased to normal levels but right atrial pressure remained elevated. All these patients were found to have associated cardiac disease, most frequently constriction. We conclude that routine determination of intrapericardial pressure: 1) reveals the presence of tamponade in cases without clinical suspicion; 2) indicates the efficacy of drainage; and 3) together with right atrial pressure recording, provides early diagnosis of associated cardiac disease, especially effusive-constrictive pericarditis.

Study of the evolution of masked bifascicular block

Masked bifascicular block (MBB) (absent or minimal S in I and VL, high R in Vi and AQRS approximately -60 degrees) is a rare condition. We have found 16 such cases in the last 12 years, thirteen male and three female, mean age 70 +/- 9 years. The conventional electrocardiogram was tabulated and the clinical features and evolution of the patients were followed over 39.1 +/- 32 months. Ten patients required pacemakers, nine because of complete atrioventricular (AV) block or increase in the previous AV block. Seven patients died (follow-up 27.3 +/- 32 months), five from heart failure. This study shows: (1) MBB is a subgroup of patients with a high risk of advanced atrioventricular block; (2) a pacemaker implant does not significantly reduce the high mortality in this group because of the severity of the underlying disease; (3) these results should be evaluated in a larger series of patients in order to confirm our provisional results.

Interatrial conduction block and retrograde activation of the left atrium and paroxysmal supraventricular tachyarrhythmia

We studied 16 patients with electrocardiographic evidence of advanced interatrial block and retrograde activation of the left atrium (P greater than or equal to 0.12 s, and diphasic (+/-) P waves in leads II, III, and VF). Eight patients had valvular heart disease, four had dilated cardiomyopathy and four had other forms of heart disease. Patients with valvular heart disease and cardiomyopathy were compared with a control group of 22 patients with similar clinical and echocardiographic characteristics, but without this type of interatrial block. Patients with advanced interatrial block and retrograde activation of the left atrium had a much higher incidence of paroxysmal supraventricular tachyarrhythmias (93.7%) during follow-up than did the control group, (27.7%) (P less than 0.001). Eleven of 16 patients (68.7%) with advanced interatrial block and retrograde activation of left atrium had atrial flutter (atypical in seven cases, typical in two cases, and with two or more morphologies in two cases). Six patients from the control group (27.7%) had sustained atrial tachyarrhythmias (five atrial fibrillation and one typical atrial flutter). The atrial tachyarrhythmias were due more to advanced interatrial block and retrograde activation of left atrium and frequent atrial extrasystoles than to left atrial enlargement, because the control group with a left atrium of the same size, but without advanced interatrial block and retrograde activation of left atrium and with less incidence of atrial extrasystoles, had a much lower incidence of paroxysmal tachycardia.