D-dimer levels and risk of recurrence following provoked venous thromboembolism: findings from the RIETE registry

BACKGROUND

Patients with venous thromboembolism (VTE) secondary to transient risk factors may develop VTE recurrences after discontinuing anticoagulation. Identifying at-risk patients could help to guide the duration of therapy.

METHODS

We used the RIETE database to assess the prognostic value of d-dimer testing after discontinuing anticoagulation to identify patients at increased risk for recurrences. Transient risk factors were classified as major (postoperative) or minor (pregnancy, oestrogen use, immobilization or recent travel).

RESULTS

In December 2018, 1655 VTE patients with transient risk factors (major 460, minor 1195) underwent d-dimer measurements after discontinuing anticoagulation. Amongst patients with major risk factors, the recurrence rate was 5.74 (95% CI: 3.19-9.57) events per 100 patient-years in those with raised d-dimer levels and 2.68 (95% CI: 1.45-4.56) in those with normal levels. Amongst patients with minor risk factors, the rates were 7.79 (95% CI: 5.71-10.4) and 3.34 (95% CI: 2.39-4.53), respectively. Patients with major risk factors and raised d-dimer levels (n = 171) had a nonsignificantly higher rate of recurrences (hazard ratio [HR]: 2.14; 95% CI: 0.96-4.79) than those with normal levels. Patients with minor risk factors and raised d-dimer levels (n = 382) had a higher rate of recurrences (HR: 2.34; 95% CI: 1.51-3.63) than those with normal levels. On multivariate analysis, raised d-dimers (HR: 1.74; 95% CI: 1.09-2.77) were associated with an increased risk for recurrences in patients with minor risk factors, not in those with major risk factors.

CONCLUSIONS

Patients with raised d-dimer levels after discontinuing anticoagulant therapy for VTE provoked by a minor transient risk factor were at an increased risk for recurrences.

Genomic copy number alterations in clear cell renal carcinoma: associations with case characteristics and mechanisms of VHL gene inactivation

Array comparative genomic hybridization was used to identify copy number alterations in clear cell renal cell carcinoma (ccRCC) patient tumors to identify associations with patient/clinical characteristics. Of 763 ccRCC patients, 412 (54%) provided frozen biopsies. Clones were analyzed for significant copy number differences, adjusting for multiple comparisons and covariates in multivariate analyses. Frequent alterations included losses on: 3p (92.2%), 14q (46.8%), 8p (38.1%), 4q (35.4%), 9p (32.3%), 9q (31.8%), 6q (30.8%), 3q (29.4%), 10q (25.7%), 13q (24.5%), 1p (23.5%) and gains on 5q (60.2%), 7q (39.6%), 7p (30.6%), 5p (26.5%), 20q (25.5%), 12q (24.8%), 12p (22.8%). Stage and grade were associated with 1p, 9p, 9q, 13q and 14q loss and 12q gain. Males had more alterations compared with females, independent of stage and grade. Significant differences in the number/types of alterations were observed by family cancer history, age at diagnosis and smoking status. Von Hippel–Lindau (VHL) gene inactivation was associated with 3p loss (P<E-05), and these cases had fewer alterations than wild-type cases. The fragile site flanking the FHIT locus (3p14.2) represented a unique breakpoint among VHL hypermethylated cases, compared with wild-type cases and those with sequence changes. This is the first study of its size to investigate copy number alterations among cases with extensive patient, clinical/risk factor information. Patients characterized by VHL wild-type gene status (vs sequence alterations) and male (vs female) cases had more copy number alterations regardless of diagnostic stage and grade, which could relate to poor prognosis.

[Demographic distribution and prevalence of overactive bladder in Venezuela]

OBJECTIVE

There is a lack of information regarding overactive bladder (OAB) in South America. Our aim in this study was to estimate the prevalence of overactive bladder (OAB) in Venezuela based on the 2002 International Continence Society (ICS) consensus criteria and also to verify its demographic distribution in this country.

SUBJECTS AND METHODS

We performed a multicentric prospective evaluation of patients from 2003 to 2007 in different cities in Venezuela. A number 3.407 adults (M:38%, F:62%) between 18 and 75 years of age (mean age 54 years) completed a physician guided questionnaire (V8) of urinary symptoms, bladder function, diet, general habits and general medical condition. Statistical procedures were carried out using software based on R programming for computational statistics.

RESULTS

The overall prevalence of OAB in Venezuela was determined as 21%. Female were more affected as compared to male (25.6% vs. 13.7% in men, p < 0.005) OAB was detected at early age (18 yrs) maintaining higher prevalence in women (M: 9%, F: 14%). In the studied cohort OAB shows its highest prevalence between the subgroup of 65 to 69 years of age. In all statistical tests the level of significance was defined as p < 0.005, with a confidence interval of 95%.

CONCLUSION

The OAB-V8 questionnaire aids to clearly identify patients with OAB symptoms. The overall prevalence of OAB in Venezuela is 21%. It is present in both genders, predominantly women and can be detected at early age.

Vitamin D receptor polymorphisms and renal cancer risk in Central and Eastern Europe

Previous studies investigated the role of vitamin D intake and cancer risk. The kidney is a major organ for vitamin D metabolism, activity, and calcium homeostasis; therefore, it was hypothesized that dietary vitamin D intake and polymorphisms in the vitamin D receptor (VDR) gene may modify renal cell carcinoma (RCC) risk. Three common VDR gene polymorphisms (BsmI, FokI, TaqI) were evaluated among 925 RCC cases and 1192 controls enrolled in a hospital-based case-control study conducted in Central and Eastern Europe. Overall associations with RCC risk were not observed; however, subgroup analyses revealed associations after stratification by median age of diagnosis and family history of cancer. Among subjects over 60 yr, reduced risks were observed among carriers of the f alleles in the FokI single-nucleotide polymorphism (SNP) (odds ratio [OR] = 0.61 for Ff and OR = 0.74 for ff genotypes) compared to subjects with the FF genotype (P trend = 0.04; P interaction = 0.004). Subjects with the BB BsmI genotype and a positive family history of cancer had lower risk compared to subjects with the bb allele (OR = 0.60; 95% CI: 0.33-1.1; P trend = 0.05). Genotype associations with these subgroups were not modified when dietary sources of vitamin D or calcium were considered. Additional studies of genetic variation in the VDR gene are warranted.

Glutathione S -transferase polymorphisms, cruciferous vegetable intake and cancer risk in the Central and Eastern European Kidney Cancer Study

High consumption of cruciferous vegetables has been associated with reduced kidney cancer risk in many studies. Isothiocyanates, thought to be responsible for the chemopreventive properties of this food group, are conjugated to glutathione by glutathione S-transferases (GSTs) before urinary excretion. Modification of this relationship by host genetic factors is unknown. We investigated cruciferous vegetable intake in 1097 cases and 1555 controls enrolled in a multicentric case-control study from the Czech Republic, Poland, Romania and Russia. To assess possible gene-diet interactions, genotyped cases (N = 925) and controls (N = 1247) for selected functional or non-synonymous polymorphisms including the GSTM1 deletion, GSTM3 3 bp deletion (IVS6 + 22-AGG) and V224I G>A substitution, GSTT1 deletion and the GSTP1 I105V A>G substitution. The odds ratio (OR) for low (less than once per month) versus high (at least once per week) intake of cruciferous vegetables was 1.29 [95% confidence interval (CI): 1.02-1.62; P-trend = 0.03]. When low intake of cruciferous vegetables (less than once per month) was stratified by GST genotype, higher kidney cancer risks were observed among individuals with the GSTT1 null (OR = 1.86; 95% CI: 1.07-3.23; P-interaction = 0.05) or with both GSTM1/T1 null genotypes (OR = 2.49; 95% CI: 1.08-5.77; P-interaction = 0.05). These data provide additional evidence for the role of cruciferous vegetables in cancer prevention among individuals with common, functional genetic polymorphisms.

A 2-d active appearance model for prostate segmentation in ultrasound images

In this research we use an active appearance model (AAM) as the core of a robust segmentation algorithm that combines contour and texture information to learn shape variability through a training procedure in trans-rectal ultrasound (TRUS) images of the prostate. Training was carried out using a dataset of 95 images which are preprocessed using gray-level mathematical morphology operators. Preliminary results are promising. The segmentation can provide shapes that have an overlap with respect to a ground truth shape, traced by an expert, of up to 96%, and an average distance from point to curve of up to 1.3 pixels.

Eating Disorders in Spanish Female Athletes

The objective of the study was to determine the prevalence of eating disorders and risk factors for their development in female athletes. Two hundred and eighty-three elite sportswomen, competing in 20 different sports, were administered the EAT, the CETCA (the Eating Disorders Assessment Questionnaire, based on DSM-III-R diagnostic criteria), and two other inventories which evaluated 1) the possible influence on eating disorders of exposure of the body in public and 2) pressure from coaches regarding eating habits, weight, physical appearance and performance. More than 11% of subjects had scores above the cut-off point (>30) on the EAT questionnaire, a proportion similar to that found in a general female population in Spain. On the basis of the CETCA score, AN was putatively diagnosed in 2.5% of the sample, and BN in 20.1%. Though some of these cases may have been EDNOS (eating disorders not otherwise specified), the proportion of athletes suffering from some kind of eating disorder was five times higher than in the general population (22.6% vs. 4.1%). No differences were found between the sportswomen and the general population in terms of specific risk behaviours and attitudes, but a substantial subgroup of athletes presented two or more of these risk behaviours. Exposure of the body in public seems to be a risk factor for eating disorders in general, and pressure from coaches seems to be a risk factor for bulimia.

Plasmapheresis for the prophylaxis and treatment of recurrent focal segmental glomerulosclerosis following renal transplant

We evaluated 10 patients with primary focal segmental glomerulosclerosis (FSGS) treated with plasmapheresis (PS) following renal transplantation. Three patients lost their first graft due to FSGS recurrence. In seven patients, PS was indicated as treatment for probable recurrence defined as the onset of proteinuria above 1 g/24 hours. In the remaining three patients, treatment was started in the first week posttransplant as prophylaxis against recurrence. The PS protocol was 17 sessions with the exchange of 2.5 L of plasma for 5% albumin over 10 to 12 weeks. Losartan (25 to 100 mg/d) was given to most patients at the end of PS treatment. The mean follow-up time after PS was 10 months. All patients currently have a functioning graft. A full response to treatment, defined as persistently reduced proteinuria to less than 500 mg/24 hours or the lack of recurrence in prophylactic treatment, was achieved in six patients. Three patients showed a partial decrease in proteinuria (to less than 1 g/24 hours). One patient failed to respond and still has nephrotic range proteinuria. No adverse effects of PS were recorded. A prompt start of PS combined with the use of losartan yields good results in the prophylaxis and treatment of recurrent FSGS following renal transplant in terms of quickly reduced proteinuria. Given the natural course of FSGS, a longer follow-up is needed to estimate the impact of PS on graft survival.

Body image, risk factors for eating disorders and sociocultural influences in Spanish adolescents

The aim was to study differences between male and female adolescents as regards body dissatisfaction, some risk factors for eating disorders, and exposure to social influences that create ideal body figures among these populations. A questionnaire comprising 40 items was administered to 240 male adolescents at 12 public and private schools in Barcelona. Twenty-nine of the questions were the same as those in another study administered to a sample of 675 female adolescents attending similar schools in the same geographical area. The other 11 questions were specifically for males. The differences between boys and girls were highly significant on almost all the items. Girls' scores were significantly higher (p = 0.000) in the following areas: dieting and exercising in order to be thin; feelings of anxiety on seeing or showing the body in public; tendency to focus on the bodies of others and on the amount of food they eat; the belief that thin people are more popular. In addition, the girls were significantly more vulnerable to potentially dangerous social influences. For the most part, males sought a heavier, more muscular body. Though a minority of males also feared being overweight, one out of four ate more than normal to gain weight and two out of three exercised to develop their muscles. The same proportion reported envying the build of certain actors. In adolescence, the ideal body figures of the sexes vary widely. This divergence reflects a greater risk of eating disorders in girls, who are also far more exposed to social situations that cause body dissatisfaction and shape risk attitudes and behaviors.

Readiness to recover in adolescent anorexia nervosa: prediction of hospital admission

OBJECTIVES

To determine if motivation to change in anorexia nervosa during treatment is a predictor of hospitalisation in adolescent patients.

METHOD

The Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ), the Eating Disorders Inventory-2 (EDI-2) and the Beck Depression Inventory (BDI) were administered to a group of 70 anorexia nervosa patients (mean age 15.6 years). They were all receiving treatment at a specialised Eating Disorder Unit and were at different points in the treatment programme. Admission during 6-9 month follow-up was recorded in 63 of these patients who had been admitted to the Unit. The other 7 patients were contacted by phone to determine if they had been hospitalised in another unit during the follow-up period.

RESULTS

Patients who needed hospital admission during follow-up had higher mean scores at first evaluation on some of the EDI-2 scales and on the BDI, lower ANSOCQ scores and were more likely to have been outpatients at first evaluation. In the logistic regression analysis a low ANSOCQ score and being an outpatient at first evaluation were shown to be independent predictors of hospitalisation during follow-up.

CONCLUSIONS

Low motivation to change, depressive symptomatology and some EDI-2 scales are related to the necessity of hospital admission in adolescent patients with anorexia nervosa.

Alendronate in Kidney Transplant Patients: A Single-Center Experience

INTRODUCTION

Osteoporosis following a renal transplant is an important cause of morbidity. Several studies have demonstrated the efficiency of diphosphonates for the prevention and treatment of osteoporosis.

METHODS

We evaluated the effect of alendronate treatment on bone mineral density (BMD) in patients with osteoporosis (lumbar spine and/or hip t-scores < or = -2.5). Two study groups were established: group A (n = 13), patients treated orally with vitamin D, calcium, and alendronate (70 mg/week) and group B (n = 12) patients receiving only vitamin D and calcium. The immunosuppression regimen mostly used was steroids and cyclosporine. BMD was determined at the lumbar spine and hip using a Hologic 4500 QDR densitometer at the start of treatment and after 1 year.

RESULTS

The study groups showed no significant differences in age, sex, menopause, or transplant time. Group A received a mean of 1.80 +/- 1.3 microg vitamin D/week and 1.3 +/- 2.1 g calcium/d, compared to 1.1 +/- 1 microg and 1.25 +/- 2.3 g, respectively for group B (NS). After a mean of 411.15 +/- 107.75 days of treatment, a significant increase in BMD at the femoral neck was recorded in group A, but not at the level of the spine (+5.57% +/- 3.5%, P < .05 and -0.42% +/- 12%, NS, respectively). No significant changes were observed in group B (-1.45% +/- 8% femoral neck and +1.69% +/- 3.5% hip, NS). Dyspepsia was reported by 7% of patients.

CONCLUSIONS

In this preliminary analysis, alendronate produced, improvements are so far limited to an increased BMD in the hip.

Validity of a measure of readiness to recover in Spanish adolescent patients with anorexia nervosa

The objective of the present study was to evaluate readiness to recover in adolescent patients with anorexia nervosa with a Spanish version of the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ). Three measures-the ANSOCQ, the Eating Disorders Inventory-2 (EDI-2) and the Beck Depression Inventory (BDI)-were administered to a group of 70 anorexia nervosa patients (mean age = 15.6 yrs) who were receiving treatment at a specialized eating disorder unit and had reached different stages of the treatment programme. The ANSOCQ was administered again after one week in 42 patients to evaluate test-retest reliability. The ANSOCQ demonstrated good internal consistency (Cronbach's alpha =.94) and one week test-retest reliability (r =.90). Negative, significant correlations were found between the ANSOCQ and several scales on the EDI-2 (r between -.50 and -.72) and the BDI (r = -.68). The Spanish version of the ANSOCQ seems a reliable instrument to evaluate readiness to recover in adolescents with anorexia nervosa.

[Interstitial pneumonitis associated with sirolimus administration in a renal transplantation patient: a clinical case]

Sirolimus is an immunosuppressive drug which has proved its effectivity to reduce the incidence of acute rejection in renal transplantation receptors. As this drug lacks nephrotoxic effects, its simultaneous use with other anticalcineurinic drugs allows the use of reduced doses. Thrombocytopenia and hyperlipidemia are the best known side-effects of sirolimus administration. Alterations in hepatic biochemistry results are also common. Some instances of interstitial pneumonitis associated to its use have been recently reported. In this paper we present a clinical case related to this rare but already confirmed adverse side-effect, which apart from the other more common nosologies occurring in immunosuppressed patients, should be taken into account in the differential diagnosis of interstitial pneumonitis in patients who are being administered this drug.

Cue exposure in the treatment of resistant bulimia nervosa

OBJECTIVE

It was hypothesized that binge eating (bulimia nervosa [BN]) may be caused by the anticipatory and immediate anxiety associated with certain types of food. Consequently, an extinction schedule should reduce binge eating.

METHODS

Cue exposure was carried out with 6 bulimic women who had responded poorly or not at all to the usual pharmacologic or cognitive-behavioral treatments.

RESULTS

Binge eating and vomiting were almost totally suppressed in the 6 patients. Symptom suppression was maintained at two follow-ups, one at 4-20 months and another at 2.5-3 years.

DISCUSSION

Cue exposure may be effective with BN that is resistant to conventional treatments. The anxiety associated with food plays an important role in provoking and/or maintaining binge eating. Motivation to change is likely to be an important mediator.

Hepatitis C and the incidence of diabetes mellitus after renal transplant: influence of new immunosuppression protocols

BACKGROUND

Hepatitis C has been associated with an increased incidence of diabetes mellitus (DM) following renal transplantation (RT).

METHODS

Patients who underwent RT between 1985 and 2001 were excluded if they showed DM prior to RT, graft survival of less than 90 days, and unknown anti-HCV status (n=15). Two groups (G1 and G2) were distinguished according to the immunosuppressive regimen: G1 (transplanted 1985-1996) received steroids, azathioprine, and cyclosporine (n=330), whereas G2 (1997-2000) received new drugs in several combinations (MMF in 87% and/or tacrolimus in 35% [n=240]). Patients with HCV antibodies pre- and/or post-RT were considered HCV-positive. Post-RT DM requiring prolonged treatment with oral antidiabetics or insulin (>1 month) was assessed using Kaplan-Meier curves and Cox analysis.

RESULTS

G2 patients were significantly older, had a greater body mass index (BMI), and suffered significantly less from acute rejection episodes during the first year than G1 patients. Furthermore, fewer required maintenance steroids. HCV-positivity was more common in G1 than in G2 (n=96, 29.1% vs n=27, 11.3%). Six G2 patients were successfully treated with interferon pre-RT, achieving negative PCR-HCV status (maintained post-RT). DM incidence at 4 years was similar in G1 and G2 (8.8% and 8.2%). G1 HCV-positive patients showed a greater risk of developing DM than HCV-negative patients (28.0% vs 6.2% at 10 years; P=001). In G1, multivariate analysis showed that age, BMI, and HCV-positivity were significant risk factors predicting DM (relative risk, 5.7; 95% confidence interval 2.7-12). In G2 patients, HCV was not associated with an increased risk of DM; in the multivariate analysis only age appeared to be a risk factor.

CONCLUSIONS

The reported relationship between hepatitis C and post-RT DM was not observed among patients receiving new immunosuppressive treatments. Confirmation of this finding requires extended follow up. The reduced use of steroids and effective pre-RT use of interferon may also be responsible for the benefit.

Osteoarticular pain and bone mineral density in renal transplantation

INTRODUCTION

The reduction of bone mineral density (BMD) levels is an important complication after renal transplantation. The prevalence of nontraumatic lesions may reach 22%. Patients with lower osseous mass suffer the highest number of lesions.

OBJECTIVE

Evaluate BMD in patients over 30-years old who have undergone renal transplantation more than 1 year prior, who attend a medical facility complaining of osteoarticular pain and were prescribed rest or any analgesia.

PATIENTS AND METHODS

One hundred twenty-three patients who received a renal transplant from a cadaveric donor from 1980 through 2000 were included in the present study to measure BMD levels in the hips and the vertebral column using a densitometer (Hologic 4500 QDR). Our study complied with WHO recommendations, which define normal values as a T score >-1 SD osteopenia as a (T score between <-1 and >-2.5 SD), and osteoporosis as a T score <-2.5 SD. Patients were divided into three groups according to gender and hormonal status. The following clinical and analytic data were collected: age, gender, race, age at onset of menopause, diabetes mellitus (DM), weight, size, retransplantation, period of evolution after transplantation, and parathormone (PTH), creatinine, and renal clearance values.

RESULTS

There were 51 men (41.1%) included. Forty postmenopausal (32.5%) and premenopausal women (26%) were also included. In all patients we observed a correlation between a reduction in BMD values and age, duration post-transplantation, and body weight (P<.05). Reduced BMD levels in premenopausal women were related with lower body weight, (P<.05) and elevated PTH levels (P<.024).

CONCLUSIONS

We observed that patients who had undergone transplantation displayed a moderately higher risk of suffering a fracture. Such risk increased in the case of women with more frequent fractures in the vertebral column. In 23.8% of patients reporting osseous pain, there was no reduction in BMD levels. Therefore, we must look for other disorder, responsible for the pain and prescribe adequate treatment.

Outcome of kidney transplant in chronic hepatitis C virus patients: effect of pretransplantation interferon-alpha2b monotherapy

Hepatitis C virus (HCV) infection represents an important problem for hemodialysis patients especially following renal transplantation. We assessed the outcome of HCV-positive patients undergoing renal transplantation after treatment during the pretransplant period with alpha-interferon 2b (alpha-IFN2b). Data from all HCV-infected patients (n=38) undergoing renal transplantation from a cadaveric donor between January 1997 and June 2002 were retrospectively reviewed. Viral clearance was achieved in 7 of 13 patients receiving alpha-IFN2b monotherapy during the pretransplant period. Controls were HCV-negative renal transplantation recipients operated during the same period (n=273). HCV-positive compared to HCV-negative patients showed no differences in age, gender, underlying disease, donor type, or immunosuppressive regimen, but there were significant differences (P<.001) in the mean (+/-SD) time on dialysis (155+/-70 versus 43+/-47 months), retransplant incidence (26% versus 5%), immunization rate as assessed by panel reactive antibodies (PRA) peak >50% (55% versus 18%), or 1-year survival of recipients (88% versus 97%) and of grafts (76% versus 89%). In contrast, all seven HCV RNA-negative patients who were before transplantation survived to the end of follow up with functioning grafts in six subjects and remained with normal liver function and clearance of HCV RNA. We conclude that kidney transplantation in HCV-positive compared with HCV-negative patients shows lower recipient and graft survival rates, possibly due to the higher incidence of risk factors, such as duration of hemodialysis, higher retransplantation rate, or hyperimmunization. Responders to pretransplantation IFN therapy show an excellent prognosis of liver function and overall outcome close to HCV-negative renal transplant recipients.

[Cost of maintenance immunosuppressive drugs in kidney transplantation]

METHOD

We calculated the cost of maintenance immunosuppression (ISM) in 405 kidney transplant patients under treatment for more than one year, classifying them according to the combination of drugs used and whether the ISM continued to be the same as initially indicated (primary ISM), or a later adaptation. Basic clinical data were also acquired on the through levels of drugs and the use and cost of the associated medication.

RESULTS

The mean doses in mg/kg/day and the trough levels in ng/ml were: cyclosporin (Cs), 2.7 +/- 0.9 and 123 +/- 5; tacrolimus (T), 0.09 +/- 0.06 y 7.3 +/- 2.9; Mycophenolate mofetil (MMF), 21.6 +/- 6.8 and 3.3 +/- 2.4. The proportion of patients with doses of steroids (EST) below 5 mg/day among patients treated with MMF was 60% in association with Cs and 73% with T. The cost related to EST and azathioprine (AZA) is very low; the mean cost per patient and day for Cs, T and MMF, was 7.08, 12.59 and 9.53 euros, respectively. The annual cost per patient depending on treatment was, in euros: EST + AZA, 204; Cs or without AZA and/or EST: 2,555; T with or without AZA and/or EST: 4,616; Cs plus MMF with/without EST: 6,136; T plus MMF with/without EST: 7,212. In cases of primary ISM, the difference between the two treatments with MMF drops so, low that its loses statistical significance (7,206 and 6,443 euros). This is because the dose of MMF is 50% higher in cases treated with Cs, even though there is no difference in the trough level of MMF. The use of hypolipidemic agents (with a mean annual cost of 451 euros) is much lower in treatments with T in comparison with Cs (13.8% vs 41.4%, p < 0.001). No significant differences could be established between T and Cs regarding the use of hypotensive agents and the frequency of postransplant insulin dependent diabetes.

CONCLUSIONS

The treatment of ISM with T is more expensive than Cs based treatment but the difference is reduced in combination with MMF because of the use of lower doses of MMF in the association of T with MMF. The considerable economic impact of ISM would justify the provision of greater resources to the rationalisation of the treatments currently being applied.

Schistosomiasis mansoni in areas of low transmission: epidemiological characterization of Venezuelan foci

Severe schistosomiasis is a rare event in Venezuela nowadays, after a successful national campaign by the Schistosomiasis Control Program. Unfortunately, this program has practically disappeared, and snail surveillance in field is not a priority, anymore. Thus, schistosomiasis has become a neglected disease in this country. However, surveys in different populations from the endemic area have shown particular epidemiological features described herein. In five communities we evaluated 2,175 persons and searched for the presence of Biomphalaria glabrata snails. Some markers were used for classifying schistosomiasis foci: mean age of the persons with Schistosoma mansoni eggs in the stools, serological tests, presence of B. glabrata snails, and intensity of infection. Places without B. glabrata snails and with few schistosomiasis cases were defined as "past transmission sites"; a site with abundant snails but few cases was defined as "potential risk"; "new transmission" foci were characterized by the presence of infected snails and young people passing eggs in the stools. A "re-emergent" focus has shared these last features, showing in addition a place where schistosomiasis had been reported before. Recent evidences of active transmission with the increasing dispersion of B. glabrata snails, point out the necessity for the re-establishment of the Schistosomiasis Control Program in Venezuela.

Adolescent anorexia nervosa: the catch-up effect in bone mineral density after recovery

OBJECTIVE

To determine whether bone mineral density (BMD) loss can be reversed in adolescent anorexic patients.

METHOD

A prospective study with 108 anorexia nervosa patients (DSM-IV) from 12 to 17 years of age at the Eating Disorders Unit in the Hospital Clinic of Barcelona (Spain). They were first evaluated by dual-energy x-ray absorptiometry in lumbar spine and femoral neck consecutively from 1997 until 1999 and reexamined after 6 to 30 months. Results were compared with normative values of bone mass.

RESULTS

Patients with poor outcome (n = 44) had a bone mass loss. Patients with good short-term outcome were divided in two groups. The group with normal BMD at first evaluation (n = 41) had a bone mass gain per year of 3.0% at lumbar spine and 0.5% at femoral neck. The group with low BMD at first evaluation (n = 23) had an increase per year of 9.1% at lumbar spine and 4.5% at femoral neck. In a multiple linear regression analysis with the variables body mass index, age, months with menstruation, and BMD zscore at first evaluation, the only predictor of BMD increase was the first z score both at the lumbar spine (coefficient R = 0.64; p < .001) and at the femoral neck (coefficient R = 0.5; p < .001).

CONCLUSIONS

There is a catch-up effect in adolescent patients with low BMD but good short-term outcome.

Cutaneous lymphomatoid granulomatosis: correlation of clinical and biologic features

Lymphomatoid granulomatosis (LYG) is a rare angiocentric and angiodestructive Epstein-Barr virus-associated B-cell lymphoproliferative disorder (EBV-BLPD), varying widely from an indolent process to an aggressive large cell lymphoma. The skin is the extrapulmonary organ most commonly involved in LYG. We studied 32 skin lesions from 20 patients with known pulmonary LYG, using immunohistochemistry, in situ hybridization for EBV, and polymerase chain reaction for the presence of antigen receptor gene rearrangements (IgH and TCR) to better define both the clinicopathologic spectrum and pathogenesis of the cutaneous lesions. We describe two distinct patterns of cutaneous involvement. Multiple erythematous dermal papules and/or subcutaneous nodules, with or without ulceration, were present in 17 patients (85%). These lesions demonstrate a marked angiocentric lymphohistiocytic infiltrate, composed predominantly of CD4-positive T-cells, with a high propensity for involving the subcutaneous tissues, and exhibiting angiodestruction, necrosis, and cytologic atypia. EBV-positive B-cells were detected in the nodules from five patients; clonal immunoglobulin heavy chain gene (IgH) rearrangements were detected by polymerase chain reaction in two patients. Multiple indurated, erythematous to white plaques were present in three patients (15%). The plaque lesions were negative for EBV and clonal IgH gene rearrangements in all cases studied. The clinical course of overall disease was variable, ranging from spontaneous regression without treatment (1 of 13; 7%), resolution with chemo/immunomodulatory therapy (8 of 13; 62%), and progression (4 of 13; 31%). The clinical and histopathologic features of cutaneous LYG are extremely diverse. However, the majority (85%) of the cutaneous lesions mirrors to some extent LYG in the lung, although EBV+ cells are less frequently identified. This subset of cases shows the histopathologic triad of angiodestruction with associated necrosis, panniculitis, and in some cases atypical lymphoid cells. The commonality of the histologic features in this group suggests a common pathophysiologic basis, possibly mediated by cytokines and chemokines induced by EBV. A small percentage of the lesions (15%) presented as indurated and atrophic plaques, and EBV was not identified in the small number of cases studied. The relationship of the plaque-like lesions to LYG remains uncertain. Whereas some cases of LYG regress spontaneously, most require therapy.

[Survival of grafts in the first 100 renal transplants at the Carlos van Buren Hospital]

BACKGROUND

Renal transplant is the best therapeutic alternative for chronic renal failure, although it is not exempt of risks.

AIM

To report the survival of renal transplant recipients and grafts and the main complications at a public hospital in Chile.

PATIENTS AND METHODS

This is a non experimental, open historical cohort study, with reposition of the first 100 transplants in 94 patients, performed at the Carlos van Buren Hospital between 1984 and 1998. Seventy grafts came from cadaveric donors and 30 from live donors. As immunosuppressive therapy, prednisone + azathioprine was used in 48 transplants and the same regimen plus cyclosporine in 52.

RESULTS

Mean age of recipients was 36 +/- 23 years old. Ten years actuarial survival of patients was 80.5% in transplants from cadaveric donors and 86% in transplants from live donors. Ten years graft survival was 57.5% in transplants from cadaveric donors and 42% in transplants from live donors. The period in which the transplant was performed (first or second half of the observation period), type of donor, HLA B-DR compatibility and sensitization (% PRA) had no effect on survival. Twenty five subjects lost their graft, 12 due to acute steroid resistant rejection, 10 due to chronic graft nephropathy and three due to renal artery thrombosis. Fifteen subjects died with a functioning graft, 10 due to infections, two due to an acute myocardial infarction, two due to an acute pancreatitis and one due to a brain tumor.

CONCLUSIONS

Survival of grafts and renal transplant recipients was not influenced by the type of donor, period of transplantation and immune variables. Main causes of recipient death were infections and the main cause of graft failure was acute rejection.

Predictors of bone mineral density reduction in adolescents with anorexia nervosa

OBJECTIVES

To determine which variables are associated with a significant reduction in bone mineral density (BMD) in adolescent anorexia nervosa and to establish guidelines for indication of bone densitometry.

METHOD

One hundred seventy patients (treated from 1997 until 1999), aged 10 to 17 years, with a DSM-IV diagnosis of anorexia nervosa were evaluated by dual-energy-x-ray absorptiometry in the lumbar spine (L2-L4) and the femoral neck. The results were compared with the normative data for BMD values by age and sex in Spanish adolescents.

RESULTS

44.1% of patients had osteopenia at the lumbar spine and 24.7% at the femoral neck. The following variables were related to osteopenia: more than 12 months since onset of the disorder (p < .001), more than 6 months of amenorrhea (p < .001), body mass index <15 (p < .001), calcium intake <600 mg/day (p < .01), and <3 hours/week of physical activity (p < .001). In a stepwise logistic regression analysis to predict reduced spinal BMD, 3 variables-months elapsed since the onset of weight loss, calcium intake, and body mass index--correctly classified 78.8% of patients.

CONCLUSIONS

Adolescent anorexia nervosa patients with the characteristics outlined above are at high risk of reduced BMD, and densitometry is recommended to determine the degree of osteopenia.

Quality of rearing practices as predictor of short-term outcome in adolescent anorexia nervosa

BACKGROUND

Studies of family relationships in anorexia nervosa have produced conflicting results. Some authors claim that family factors are related to short-term outcomes.

METHODS

Perceived rearing practices, as measured by the EMBU (Egna Minnen Betraffande Uppfostran: 'My memories of Upbringing') were examined in a sample (N = 158) of adolescents with anorexia nervosa and compared with the perceptions of adolescents (N = 159) from the general population. A further comparison was made between the groups of patients with good and bad short-term outcomes. Logistic regression analysis was performed to evaluate the predictive value of different variables on short-term outcome.

RESULTS

Overall, small differences were observed in the perceptions of rearing practices as expressed by the controls and the anorexic patients. Patients with bad short-term outcome perceived more rejection and control-overprotection from both parents than those with good outcome. In the logistic regression analysis only Rejection from father and the EAT (Eating Attitudes Test) total score gave independent prediction of treatment response.

CONCLUSIONS

Taken as a whole, these results do not support the idea of altered rearing practices in anorexic patients, at least in young patients with a short evolution of the disease. Perceived rearing practices, especially 'rejection', appear to have an appreciable effect on the short-term outcome.

Anorexia nervosa in a Spanish adolescent sample: an 8-year longitudinal study

OBJECTIVE

The aim of this study was to determine the intermediate-term outcome of a sample of Spanish children and adolescents with anorexia nervosa (AN).

METHOD

A total of 48 female patients were evaluated at a mean follow-up time of 8 years by means of the Psychiatric Status Rating Scale, the Morgan and Russell Outcome Scale, a structured DSM-III interview and several self-report questionnaires. Their scores were compared with a sex- and age-matched control group.

RESULTS

Three patients (6%) still had AN, two (4%) had partial syndromes of anorexia, 11 patients (23%) had recovered but still showed concern about food/body weight and 32 patients (67%) had recovered completely. The crude mortality rate was 2%.

CONCLUSION

The majority of this sample of children and adolescents with anorexia nervosa sample recovered. Perfectionism and interpersonal distrust were significantly more common in the anorexic patients than in the controls. Depression and phobias, including social phobia, were the most common comorbid psychiatric diagnoses at follow-up.

The Body Attitude Test: validation of the Spanish version

A Spanish version of the Body Attitude Test (BAT) is presented. It was validated with 165 eating disorder patients (79 anorexia nervosa, 86 bulimia nervosa) and 220 schoolgirls from the general population. Factor analysis allowed the extraction of four factors, as in the original questionnaire, but with different item loadings on each. Taken together, these four factors accounted for 67.1% of the variance. The alpha reliability coefficient was 0.92 in both groups. The test-retest reliability with a one-week interval was 0.91 in a subgroup of 34 eating disorder patients and in a subgroup of 43 girls from the general population. The difference between the mean scores of the girls from the general population and the anorexics on one hand and the bulimics on the other was highly significant (p < 0.0001). On the basis of the discriminant validity study, the use of a cut-off point of 41--which gives a sensitivity of 75.1% and a specificity of 72.7%--is recommended.

Parenting style in relation to pathogenic and protective factors of Type A behaviour pattern

BACKGROUND

Studies of type A behaviour pattern suggest that it can be promoted as a whole by certain parental rearing styles. However, the association of the different components of the type A behaviour with specific rearing practices has not been clarified.

METHOD

The relationship between parents' rearing style and the different type A behaviour components of their children was analysed in a sample of 312 university students. Parental rearing style was assessed with the EMBU, a Swedish measure originally designed to assess one's recollections concerning one's parents rearing behaviour. Type A pattern was measured by the JAS, a self-administered questionnaire that gives the global type A score and three of its components.

RESULTS

Hard Driving was related to Rejection and Favouring Subject in males. Speed-Impatience was related to Rejection and Control in both sexes, and Job Involvement was related to Control and Favouring Subject in females. In a discriminant factor analysis in males, Rejection, Control and Favouring Subject on the part of fathers classified correctly 80% of the subjects identified as having high or low Speed-Impatience and the variables of Rejection and Favouring Subject (also by fathers) classified correctly 69.23% of the subjects identified as high or low Hard Driving. In females, Control and Favouring Subject on the part of mothers and low Rejection by fathers classified correctly 70.37% of the subjects with high or low Job Involvement.

CONCLUSION

These results suggest that different rearing characteristics are related to the various components of the type A behaviour pattern.

Dermatologic manifestations of Hermansky-Pudlak syndrome in patients with and without a 16-base pair duplication in the HPS1 gene

BACKGROUND

Hermansky-Pudlak syndrome (HPS) consists of oculocutaneous albinism, a platelet storage pool deficiency, and lysosomal accumulation of ceroid lipofuscin. Patients with HPS from northwest Puerto Rico are homozygous for a 16-base pair (bp) duplication in exon 15 of HPS1, a gene on chromosome 10q23 known to cause the disorder.

OBJECTIVE

To determine the dermatologic findings of patients with HPS.

DESIGN

Survey of inpatients with HPS by physical examination.

SETTING

National Institutes of Health Clinical Center, Bethesda, Md (a tertiary referral hospital).

PATIENTS

Sixty-five patients aged 3 to 54 years were diagnosed on the basis of the absence of platelet dense bodies in individuals with albinism and a bleeding diathesis. The presence of a 16-bp duplication in HPS1 was determined by polymerase chain reaction amplification; 40 patients were homozygous for the duplication and 25 lacked the duplication. All patients with the duplication were from northwest Puerto Rico; all patients without the duplication were non-Puerto Rican except 4 from central Puerto Rico.

RESULTS

Both patients homozygous for the 16-bp duplication and patients without the duplication displayed skin color ranging from white to light brown. Patients with the duplication, as well as those lacking the duplication, had hair color ranging from white to brown and eye color ranging from blue to brown. New findings in both groups of patients with HPS were melanocytic nevi with dysplastic features, acanthosis nigricans-like lesions in the axilla and neck, and trichomegaly. Eighty percent of patients with the duplication exhibited features of solar damage, including multiple freckles, stellate lentigines, actinic keratoses, and, occasionally, basal cell or squamous cell carcinomas. Only 8% of patients lacking the 16-bp duplication displayed these findings. As a group, the patients with the duplication lived closer to the equator than those without the duplication.

CONCLUSION

Patients with HPS exhibit wide variation in pigmentation and dermatologic findings.

[The relationship of Campylobacter jejuni subsp. jejuni enterotoxigenicity and the increase of cAMP and electrolyte changes in the rat intestine]

BACKGROUND

Small intestine alterations produced by the enterotoxigenic capacity of Campylobacter jejuni subsp. jejuni are similar to the hydric, electrolytic and pathological changes caused by choleraic and thermolabile Escherichia coli toxins.

AIM

To study the enterotoxigenic capacity of 4 strains of Campylobacter jejuni subsp. jejuni using the intestinal loop model.

MATERIAL AND METHODS

Rat intestinal loops were inoculated with culture filtrates of the four strains. Enterotoxigenicity was assessed by fluid accumulation, the increase in Na+ and Cl- in the loop fluid, and cAMP increase in loop tissues. An enterotoxigenic Escherichia coil strain and sterile Brucella both were used as positive and negative controls, respectively.

RESULTS

The filtrates of two strains produced fluid accumulation in the loops, significantly increased Na+ and Cl- secretion to the intestinal lumen and increased tissue cAMP levels.

CONCLUSIONS

Some strains of Campylobacter jejuni subsp. jejuni are able to show enterotoxigenicity in vivo, increasing cAMP levels in the intestinal cells and altering electrolyte exchange mechanisms.

Subjective body-image dimensions in normal and anorexic adolescents

The subjective body dimensions of adolescent anorexic patients and adolescents from the general population were studied by means of a new technique that combines certain characteristics of the 'body-site estimation' and the 'whole-image adjustment' procedures. The technique used (Subjective Body Dimensions Apparatus-SBDA) reveals the individual's idea of the size of the different parts of his/her body, and produces a life-size global silhouette. Eighty-five female anorexic patients (ages 12 to 18) were compared with 427 adolescents from the general population. The technique showed acceptable test-retest stability. The comparison group overestimated their thorax, waist and hips, and anorexic patients overestimated all parts of their body but their thorax, waist and hips especially. For all parts of the body, the anorexic group showed greater overestimation (p < .0001) than the comparison group.

An outbreak of hantavirus pulmonary syndrome, Chile, 1997

An outbreak of 25 cases of Andes virus-associated hantavirus pulmonary syndrome (HPS) was recognized in southern Chile from July 1997 through January 1998. In addition to the HPS patients, three persons with mild hantaviral disease and one person with asymptomatic acute infection were identified. Epidemiologic studies suggested person-to-person transmission in two of three family clusters. Ecologic studies showed very high densities of several species of sigmodontine rodents in the area.

Assessing rearing behaviour from the perspectives of the parents: a new form of the EMBU

The EMBU (Egna Minnen Beträffande Uppfostran) is a self-reporting questionnaire developed to assess memories of adults about their parents' rearing practices. In the present study, an exploratory factor analysis was carried out on items of the EMBU-P, a new version of the EMBU especially designed to obtain ratings from parents about their own rearing behaviour with their children. The factor analysis yielded a structure similar to that obtained with the original EMBU (Rejection, Emotional Warmth, Control Attempts and Favouring Subject), but composed of fewer items. The internal consistency was adequate for the three major scales. Some significant correlations emerged between the EMBU-P scales. The Rejection scale correlated negatively with the Emotional Warmth scale and positively with the Control Attempts scale. The latter also correlated positively with Emotional Warmth. There were no significant correlations between the scales and the age of the parents. The sex of the parents was significantly associated with the EMBU-P scores.

[Wernicke's encephalopathy and dialysis: report of two cases]

Wernicke encephalopathy is considered a complication of dialytic therapy, but there are few reports of this complication. We report a 57 years old man and a 45 years old woman, with grade IV renal failure, who after acute peritoneodialysis and chronic hemodialysis respectively, had a confusional syndrome that responded to the administration of thiamine. CT scans in both patients discarded abnormal blood collections or new cerebrovascular episodes. The man bad two previous cerebrovascular episodes, a severe anemia that was corrected, angina and an episode of arrhythmia during the dialytic procedure previous to the confusional episode. The woman had an acute uremic syndrome and a concomitant urinary tract infection during the confusional episode. Wernicke encephalopathy must be suspected in patients in dialysis with confusional episodes.

[Clinical, psychological and biological variables in a group of 108 adolescent patients with anorexia nervosa]

BACKGROUND

To assess the clinical and psychological characteristics, hormonal changes derived from malnutrition and the prognostic factors in an adolescent group of patients with anorexia nervosa.

PATIENTS AND METHODS

In this retrospective study specific case-history medical record for this disorder was used first with the parents and later with the patients. Depression questionnaires (BDI or CDI) and eating disorders questionnaires (EAT and CIMEC) were also administered, and hormonal tests were carried out.

RESULTS

98 out of 108 patients (90.7%) were females. Mean age was 15 years, 23 patients (21.1%) showed major depressive disorders or obsessive-compulsive disorders besides anorexia nervosa. The duration of the disorder was 12.0 +/- 9.0 months. The age at onset of the disorder was 15.1 +/- 1.5 (10-17 years), and the percentage of weight loss ranged between 15.53%. In relation to the hormonal findings the low levels of T3, insulin, somatomedin, prolactin, LH and 17 B estradiol were shown up. There were no differences between inpatients and outpatients in relation to the age of onset of the disorder onset, duration of the disorder, percentage of weight loss, psychological variables or applied hormonal findings. There were differences in relation to the used psychometric tests, which differentiated between patients with a good and bad outcome.

CONCLUSIONS

Major depressive disorders and obsessive-compulsive disorders are the most frequent comorbid psychiatric disorders in the anorexia nervosa. The age at onset of the disorder, duration of the disorder, percentage of weight loss and hormonal changes do not seem to influence in outcome, whereas initial affective and eating symptomatology tend to predict disorder outcome.