[Social trajectory and schizophrenia]

On the occasion of the Clozapine symposium we have had cause to reflect on the social life-histories of schizophrenic patients. After an analysis of a cohort of 40 patients aged over 65 years, whose medical records had been kept up since the start of their disease, we have set up a methodology which enables us to study the social life-histories of these patients. Our aim is ultimately to compare the course of the disease with the treatments received by these patients and the therapeutic structures they have been offered. For this purpose, we shall study three criteria of social exposure: 1) Autonomy, 2) Integration into the family, 3) Integration through work. The aim of the present paper is to record our initial analytical findings in these three years.

Identification of three novel mutations in hereditary protein S deficiency

We report the application of single-stranded conformation polymorphism (SSCP) analysis to the screening of 15 functionally important Protein S (PS) gene (PS alpha) regions (4.243 Kb) in 6 unrelated families with PS deficiencies. Direct sequencing of the fragments with altered migration patterns led to the identification of the corresponding molecular alterations. A missense mutation, G to T transversion at codon Cys598, and two different alterations, leading either to allelic exclusion, or premature termination of the protein translation: a G to A transition at codon Trp465 and a 1 nt (T) insertion at codon 265, were identified. The 1 nt insertion was observed in three apparently unrelated families but with a common geographical origin and the mutated allele was undetectable in platelet mRNAs of affected individuals. Family analysis confirmed, in each case, a perfect cosegregation of the mutation with the PS deficiency. We conclude that these alterations represent the causative mutations.

The characteristics of epilepsy in a largely untreated population in rural Ecuador

A house-to-house survey of epileptic seizures covering a population of 72,121 persons was carried out in a rural area of northern Ecuador. A cascade system of diagnosis was used to identify all cases of epileptic seizures in this population. 1029 cases were found, of whom 881 were considered to be definite cases and 148 were possible cases. Of the 1029 cases, 56% had active epilepsy. The lifetime prevalence rate was found to lie between 12.2 and 19.5/1000 and the prevalence of active cases between 6.7 and 8.0/1000. An annual incidence rate of between 122/100,000 and 190/100,000 was estimated. Seizure type was classified without EEG data and almost half of the cases had partial seizures. In 27% of cases an aetiology was proposed on clinical grounds. This is one of few reported studies of a population that has been largely unexposed to antiepileptic drugs, providing an opportunity to study the natural history of the untreated condition. It has been suggested that treatment in newly developing epilepsy will prevent its development to a chronic condition. Only 37% of the 1029 cases had ever received antiepileptic drugs, and only 12% of the cases were taking them at the time of the survey. Despite this, a high rate of inactivity was observed, with 44% of all cases free of seizures. Nearly two thirds of the inactive cases identified had never received treatment with antiepileptic drugs. In a subgroup of untreated cases with an active condition, treatment with antiepileptic drugs was initiated and was highly effective even in cases with a long previous history. Thus the findings from this study suggest that the development of epilepsy resistant to therapy is not always associated with a long duration of untreated epilepsy.

[Identification of a period of renal ischemic vulnerability studying the changes in the indicators of acute renal insufficiency after heart surgery with extracorporeal circulation]

We studied the pre operative status and the 1st, 4th, 12th and 24th hours of the post operative period after open heart surgery with cardiopulmonary bypass with a crystalloid solution containing 10 gr of mannitol. We considered acute renal failure (ARF) as being any increase in plasma creatinine values of 0.25 mg/dl for the first 24 hours and 0.5 mg/dl for periods longer than 24 hours. Six patients had transitory ARF (28.5%). The maximum value of plasma creatinine was 2.3 mg/dl and no patients required renal function substitution. There were no deaths. We used as ischemia ARF indicators the urinary flow rate, urine/plasma creatinine ratio, urine/plasma osmolality ratio, sodium fractional excretion and free water reabsorption. We also measured the urinary N-A-Glucosaminidase (NAG). We found that creatinine clearance reached its lowest in the first and fourth hours. Beyond the fourth hour we observed, the urinary flow rate reduce significantly, the urine/plasma creatinine and osmolality ratios reach values traditionally associated prerenal ARF, an increase main free water reabsorption and a decrease in sodium fractional excretion with a close relationship between the less than 1 value and the increase in plasma creatinine. There was a significant NAG increase in the 24 th hour. The evidence of a vulnerability period for renal ischemic lesions between the 4 th and 12 th hour suggests a second mannitol administration during the first four hours of the post operative period.

[Prevention of thrombogenesis in the extracorporeal circuit of hemodialysis with a low molecular heparin: standardization of the dosage with a better hemorrhagic risk/effectiveness ratio]

PURPOSE

To test the efficacy and safety of a low molecular. Weight heparin (LMWH)--Fraxiparine, for hemodialysis (HD) anticoagulation, compared with conventional heparin (H) or serum lavage without other anticoagulation (L).

DESIGN

Prospective controlled study.

PATIENTS AND METHODS

Twenty-nine consecutive patients referred for dialysis in a tertiary care hospital were divided in 3 groups A, B and C, each group A and B patient submitted to 2 dialysis, AI and AII, BI and BII. Group A--n = 10, no bleeding risk, single needle technique, blood flow (Qb) less than 200 ml/min. HD-AI used LMWH 10,000 U pre-HD, HD-AII used H for an ACT 1.5 to 2 times baseline; group B--n = 10, high bleeding risk, double needle dialysis, Qb--200 to 300 ml/min. HD-BI used LMWH 5000 U pre-HD, and HD-BII used only L; Group C--n = 9, no bleeding risk, Qb less than 200 ml/min, all received LMWH 5000 U pre-HD. A semiquantitative screening was done in each dialysis for the presence of dialyser or venous chamber clots, APTT and Anti Xa activity were measured every 30 min., as well as pre and post-dialysis Hb, Htc, and platelets.

RESULTS

APTT didn't rise significantly during HD with LMWH in contrast with the AII group with H (32.2 +/- 7.1 vs 63 +/- 25.8, p less than 0.05). The APTT levels in all dialysis with LMWH were identical to BII dialysis With L. Anti xa activity had an early peak at 30 to 60 min. With LMWH (0.62 +/- 0.45 em AI) and a late one at 180 min with H (0.39 +/- 0.2). There was no significant differences between pre and post-dialysis corrected platelet counts, but the lavage group showed the greater decrements (-20% +/- 24). In all the 49 dialysis we had 5 cases of complete clotting of the blood circuit, all of them in the lavage group C. No patients with high risk of hemorrhage had any bleeding increment.

CONCLUSION

LMWH prevents clotting as effectively as H, in low doses of 5000 anti Xa units it doesn't interfere with PTT and is far more effective than HD with serum lavage in patients with bleeding risk and/or low blood flow in the dialysis circuit.

A large-scale study of epilepsy in Ecuador: methodological aspects

The methodology is presented of a large-scale study of epilepsy carried out in a highland area in northern Ecuador, South America, covering a population of 72,121 people; The study was carried out in two phases, the first, a cross-sectional phase, consisted of a house-to-house survey of all persons in this population, screening for epileptic seizures using a specially designed questionnaire. Possible cases identified in screening were assessed in a cascade diagnostic procedure applied by general doctors and neurologists. Its objectives were: to establish a comprehensive epidemiological profile of epileptic seizures; to describe the clinical phenomenology of this condition in the community; to validate methods for diagnosis and classification of epileptic seizures by a non-specialised team; and to ascertain the community's knowledge, attitudes and practices regarding epilepsy. A sample was selected in this phase in order to study the social aspects of epilepsy in this community. The second phase, which was longitudinal, assessed the ability of non-specialist care in the treatment of epilepsy. It consisted of a prospective clinical trial of antiepileptic therapy in untreated patients using two standard anti-epileptic drugs. Patients were followed for 12 months by a multidisciplinary team consisting of a primary health worker, rural doctor, neurologist, anthropologist, and psychologist. Standardised, reproducible instruments and methods were used. This study was carried out through co-operation between the medical profession, political agencies and the pharmaceutical industry, at an international level. We consider this a model for further large-scale studies of this type.

[The respiratory system in Arctocephalus australis (Pinnipedia, Otariidae). I--Macroanatomy and microanatomy of the trachea and extrapulmonary airways]

This paper presents the results of histological and histochemical organization of trachea and primary bronchi. The presence of a subepithelial lamina and a smooth muscle layer in the superficial corion, probably related with a functional respiratory mechanism are defined. The structure of tracheal and primary bronchi glands, the way they secretes and the type of secretion are also described.

[Hemostatic changes associated with recombinant human erythropoietin (rHu Epo) treatment]

End-stage chronic renal failure (CRF) is often associated with platelet' disfunction and therefore with impaired hemostasis. Several investigators have reported that rHu Epo, used in the treatment of CRF anaemia, is able to activate a broad spectrum of hematopoietic stem cells, and therefore is able to increase the number of platelets and to induce correction of platelet disfunction. In order to investigate hemostasis changes associated with rHu Epo we studied 8 dialysis patients before and 12 weeks after rHu Epo. RHu Epo did not induce any change in the number of platelets (187710 +/- 52690 vs 204430 +/- 68710; p = NS), but seemed to improve its function (MI% of aggregation with ADP: 46.3 +/- 4.4% vs 49.1 +/- 5.3%; p less than 0.05). There was an improvement in PT (79.0 +/- 3.0% vs 87.5 +/- 8.9%; p less than 0.02) and aPTT (33.3 +/- 5.9" vs 29.3 +/- 2.1"; p less than 0.05) suggesting an improvement in platelet coagulant activities. These preliminary results indicate that rHu Epo does not increase the number of platelets but can induce a correction of platelet disfunction.

Treatment of Brucella melitensis infection in mice by use of liposome-encapsulated gentamicin

Liposomes with entrapped gentamicin were used to treat mice with infection attributable to Brucella melitensis. Liposomes bearing positive charge and formed by egg yolk lecithin, cholesterol, and stearylamine were effective in the elimination of B melitensis residing in liver and spleen. Negatively charged liposomes, formed by egg yolk lecithin, cholesterol, and dicetyl phosphate were also effective in suppression of the infection in liver, but were less so in suppression of the infection in the spleen. Free gentamicin was less effective than the encapsulated antibiotic. At 20 hours after administration of gentamicin encapsulated in liposomes, the gentamicin concentrations in liver and spleen were similar, regardless of the charge of the liposomes--neutral, positive, or negative. However, positively charged liposomes were more efficient than were other liposome types for the treatment of brucellosis caused by B melitensis.

Evaluation of 2 intravenous thrombolytic agents (anisoylated plasminogen streptokinase activator complex versus streptokinase) in patients with acute myocardial infarction

Ten patients with symptoms of acute myocardial infarction of less than 6 hours duration were randomised to receive either anisoylated plasminogen streptokinase activator complex [APSAC] (30U) or streptokinase (1,500,000U) intravenously. The aims of the study were to compare the angiographic patency of the infarct-related coronary arteries and to monitor drug safety and tolerance for up to 24 hours. The left anterior descending artery was occluded in 3, the left circumflex in 3 and right coronary artery in 4 patients. Time between onset of pain and treatment ranged from 150 to 330 minutes. At 90 minutes, 8 patients, 3 of 5 (60%) of the APSAC group and all of the streptokinase group, had patent arteries. No significant differences were found in measurements of coagulation. There were no haemorrhagic complications. One patient of the APSAC group had reinfarction 6 hours after treatment and died in cardiogenic shock. APSAC seems safe and is easier to use than streptokinase, and both agents result in patency in the majority of patients, although too few patients were included to allow a valid comparison. However, thrombolysis should be considered only a temporary solution in acute myocardial infarction, associated mainly with 3-vessel disease.