Analysis of drug resistance-associated mutations in treatment-naïve individuals infected with different genetic forms of HIV-1 circulating in countries of the former Soviet Union

There are few data on drug resistance-associated mutations in the former Soviet Union since, studies have usually been focused on the env or gag genes for subtype information. This study examines the prevalence and patterns of resistance-associated mutations to reverse transcriptase and protease inhibitors (RTI, PRI) in 278 HIV-1-infected treatment-naïve subjects from countries of Eastern Europe, and defines characteristic polymorphisms of RT and PR sequences in HIV-1 subtype A viruses. Blood samples were collected between 1997 and 2004. Plasma RNA was used for PR-RT amplification by reverse transcription coupled with nested PCR and sequencing. Phylogenetic analysis was done with neighbor-joining trees and bootscanning. Analysis of drug resistance mutations, with Stanford University HIV Drug Resistance Database's algorithm, resulted in an overall prevalence of 12.9% resistance to RTI and 3.9% to PRI. The most frequent substitutions in the RT region were at positions 62 and 236. V77I substitution in PR was found in 47.8% of samples. Polymorphisms in subtype A sequences were identified. This is the first study reporting the prevalence and patterns of both PRI and RTI resistance-associated mutations in naïve HIV-1 infected patients from the former Soviet Union. These data underline the importance of genotypic resistance testing of chronically HIV-1-infected patients before initiating treatment, in order to select the most suitable drug regimen.

[Abrikossoff tumor of the proximal esophagus misdiagnosed as a thyroid nodule]

The diagnosis of thyroid nodules is straightforward and rarely mistaken. We present a case of a paraesophageal granular cell tumor, discovered incidentally during surgery for what it was diagnosed as a suspicious thyroid nodule by ultrasound and FNA. Complete resection was achieved without disruption of the esophageal mucosa. A terminal branch of the recurrent laryngeal nerve had to be resected en bloc with the tumor. Morphological and immunohistochemical diagnosis was established postoperatively. A review of the literature is presented.

Natural resistance-associated mutations to Enfuvirtide (T20) and polymorphisms in the gp41 region of different HIV-1 genetic forms from T20 naive patients

BACKGROUND

The natural occurrence of primary resistance mutations in reverse transcriptase (RT) and protease (PR) genes of HIV-1 isolates from untreated patients has been reported and it may have important implications for the response to drug treatment. It is predictable that the same occurs in the HR1 region of gp41 sequence from patients who have never received T20 therapy, and in this regard it would be important to know not only the mutation frequencies at HR1 region but also the natural polymorphisms at resistance-associated positions present in the absence of this drug.

OBJECTIVES

The objectives of this study are to investigate the existence of natural resistance-associated mutations to T20 in HR1 gp41 region corresponding to different HIV-1 genetic forms from T20 naive patients and to determine their prevalence.

STUDY DESIGN

Two hundred HIV-1 gp41 sequences were included: subtype B: 164 (81.3%); subtype A: 15 (8.2%); subtype G: 10 (4.6%); subtype F: 6 (3.5%); subtype C: 3 (1.8%); subtype K: 1 (0.6%); and subtype D: 1 (0.6%). We analyzed the resistance-associated mutations previously described: Q32H/R, G36D/S, I37V, V38A/M, Q39R/H, Q40H, N42T/D/Q/H, N43D/S/K/Q, L44M, L45M, R46M and V69I.

RESULTS

Natural resistance mutations to T20 were found at a high frequency: 10.5%, corresponding to 9.1% in subtype B and 16.7% in non-B subtype samples. Polymorphisms were more frequent in non-B and recombinant forms than in subtype B (p<0.001). Different substitutions were related to subtypes: N42S in subtypes A, B, G and C, but not in F, Q56R in subtype A from CRF02_AG, and L54M in subtype B from CRF14_BG.

CONCLUSIONS

To our knowledge this is the first study describing natural-resistance to T20 among different HIV-1 subtypes, warranting a study of the biological significance of this mutations and their clinical relevance. The detection of differences between subtypes may have an influence on the rate and patterns of resistance in patients undergoing T20 treatment.

IL-7 is a potent and proviral strain-specific inducer of latent HIV-1 cellular reservoirs of infected individuals on virally suppressive HAART

The persistence of HIV-1 in virally suppressed infected individuals on highly active antiretroviral therapy (HAART) remains a major therapeutic problem. The use of cytokines has been envisioned as an additional therapeutic strategy to stimulate latent proviruses in these individuals. Immune activation therapy using IL-2 has shown some promise. In the present study, we found that IL-7 was significantly more effective at enhancing HIV-1 proviral reactivation than either IL-2 alone or IL-2 combined with phytohemagglutinin (PHA) in CD8-depleted PBMCs. IL-7 also showed a positive trend for inducing proviral reactivation from resting CD4(+) T lymphocytes from HIV-1-infected patients on suppressive HAART. Moreover, the phylogenetic analyses of viral envelope gp120 genes from induced viruses indicated that distinct proviral quasispecies had been activated by IL-7, as compared with those activated by the PHA/IL-2 treatment. These studies thus demonstrate that different activators of proviral latency may perturb and potentially deplete only selected, specific portions of the proviral archive in virally suppressed individuals. The known immunomodulatory effects of IL-7 could be combined with its ability to stimulate HIV-1 replication from resting CD4(+) T lymphocytes, in addition to other moieties, to potentially deplete HIV-1 reservoirs and lead to the rational design of immune-antiretroviral approaches.

Pneumococcal bacteremia in children: an 8-year review in two hospitals in Barcelona

In this study, 90 episodes of pneumococcal bacteremia that occurred over an 8-year period in two hospitals in Barcelona were analyzed retrospectively to determine the clinical and bacteriological characteristics of pneumococcal bacteremia, the risk factors for antibiotic resistance, the outcome, and the vaccine coverage. The mean age of the patients was 3.1 years and the male/female ratio was 1.7. The overall rates of penicillin-non-susceptible, cefotaxime-non-susceptible, and erythromycin-resistant isolates were 48.8, 24.4, and 25.5%, respectively. Antibiotic resistance was associated with children under the age of 2 years and with previous antibiotic treatment. The percentage of antibiotic resistance was higher in the nine episodes that occurred in patients with an underlying illness. The most prevalent serotypes identified were 1, 14, 6B, 18C, 5, and 19A. Serotypes 6A/B, 14, and 19A/F were isolated primarily from children under 2, whereas serotypes 1 and 5 were recovered more frequently from older children. Apparent relationships between serotypes 6A/B, 14, and 19A/F and occult bacteremia and between serotypes 1 and 5 and bacteremic pneumonia were confounded by the age variable. The proportion of bacteremic episodes preventable by all (7-valent, 9-valent, and 11-valent) of the conjugate pneumococcal vaccines was 60% in children under 2. In older children, the serotype coverage rate for the three formulations was 48, 87, and 87%, respectively. In summary, these data expand upon previous Spanish studies in which serotypes 1 and 5 were reported to be among the leading causes of severe systemic pneumococcal infections in children over 2, findings that should be taken into consideration when planning vaccine programmes.

The epidemiology of depersonalisation and derealisation. A systematic review

BACKGROUND

Symptoms of depersonalisation (DP) and derealisation (DR) are increasingly recognised in both clinical and non-clinical settings, but their importance and underlying pathophysiology is only now being addressed.

METHODS

This paper is a systematic review of the current state of knowledge about the prevalence of depersonalisation and derealisation using computerised databases and citation searches. All potential studies were examined and numerical data included. Three categories of study are reviewed: questionnaire and interview surveys of selected student and non-clinical samples; population-based community surveys using standardised diagnostic interviews; and clinical surveys of depersonalisation/derealisation symptoms occurring within inpatients with psychiatric disorders. In addition, we present newly analysed data of the prevalence of depersonalisation/derealisation from five large population-based studies.

RESULTS

Epidemiological surveys demonstrate that transient symptoms of depersonalisation/derealisation in the general population are common, with a lifetime prevalence rate of between 26 and 74% and between 31 and 66% at the time of a traumatic event. Community surveys employing standardised diagnostic interviews reveal rates of between 1.2 and 1.7 % for one month prevalence in a UK sample and a 2.4% current prevalence rate in a Canadian sample. Current prevalence rates in samples of consecutive inpatient admissions are reported between 1 and 16%, although screening measures employed may have resulted in these being an underestimate. Prevalence rates in clinical samples of specific psychiatric disorders vary between 30% of war veterans with PTSD and 60% of those with unipolar depression. There is a high prevalence within panic disorder with rates varying from 7.8 to 82.6%.

DISCUSSION

DP and DR symptoms are common in normal and psychiatric populations, but prevalence estimates are hampered by inconsistent definitions and the use of variable time-frames. Population-based surveys using diagnostic interviews yield prevalence rates of clinically significant DP/DR in the region of 1-2%. Surveys of clinical populations in which common screening and assessment instruments were used also yield consistently high prevalence rates. The use of reliable diagnostic assessments and rating scales is needed. The relationship between DP/DR and certain other psychiatric disorders (e. g. panic) suggests possible common pathophysiological or aetiological factors.

Depersonalisation disorder: a cognitive–behavioural conceptualisation

Depersonalisation (DP) and derealisation (DR) are subjective experiences of unreality in, respectively, one's sense of self and the outside world. These experiences occur on a continuum from transient episodes that are frequently reported in healthy individuals under certain situational conditions to a chronic psychiatric disorder that causes considerable distress (depersonalisation disorder, DPD). Despite the relatively high rates of reporting these symptoms, little research has been conducted into psychological treatments for this disorder. We suggest that there is compelling evidence to link DPD with the anxiety disorders, particularly panic. This paper proposes that it is the catastrophic appraisal of the normally transient symptoms of DP/DR that results in the development of a chronic disorder. We suggest that if DP/DR symptoms are misinterpreted as indicative of severe mental illness or brain dysfunction, a vicious cycle of increasing anxiety and consequently increased DP/DR symptoms will result. Moreover, cognitive and behavioural responses to symptoms such as specific avoidances, 'safety behaviours' and cognitive biases serve to maintain the disorder by increasing awareness of the symptoms, heightening the perceived threat and preventing disconfirmation of the catastrophic misinterpretations. A coherent model facilitates the development of potentially effective cognitive and behavioural interventions.

Therapeutic effects of psyllium in type 2 diabetic patients

OBJECTIVE

The aim of this study was to evaluate the effects of psyllium in type 2 diabetic patients.

DESIGN

The study included three phases: phase 1 (1 week), phase 2 (treatment, 14 g fibre/day, 6 weeks) and phase 3 (4 weeks). At the end of each phase a clinical evaluation was performed after the ingestion of a test breakfast of 1824.2 kJ (436 kcal). Measurements included concentrations of blood glucose, insulin, fructosamine, GHbA(1c), C-peptide and 24 h urinary glucose excretion. In addition, uric acid, cholesterol and several mineral and vitamin concentrations were also evaluated.

SETTING

The study was performed at the Department of Pharmacology, Toxicology and Nursing at the University of León (Spain).

SUBJECTS

Twenty type 2 diabetic patients (12 men and 8 women) participated in the study with a mean age of 67.4 y for men and 66 y for women. The mean body mass index of men was 28.2 kg/m(2) and that of women 25.9 kg/m(2).

RESULTS

Glucose absorption decreased significantly in the presence of psyllium (12.2%); this reduction is not associated with an important change in insulin levels (5%). GHbA(1c), C-peptide and 24 h urinary glucose excretion decreased (3.8, 14.9 and 22.5%, respectively) during the treatment with fibre (no significant differences) as well as fructosamine (10.9%, significant differences). Psyllium also reduced total and LDL cholesterol (7.7 and 9.2%, respectively, significant differences), and uric acid (10%, significant difference). Minerals and vitamins did not show important changes, except sodium that increased significantly after psyllium administration.

CONCLUSIONS

The results obtained indicate a beneficial therapeutic effect of psyllium (Plantaben) in the metabolic control of type 2 diabetics as well as in lowering the risk of coronary heart disease. We also conclude that consumption of this fibre does not adversely affect either mineral or vitamin A and E concentrations. Finally, for a greater effectiveness, psyllium treatment should be individually evaluated.

Separating depersonalisation and derealisation: the relevance of the "lesion method"

OBJECTIVES

Depersonalisation (DP) and derealisation (DR) are often met with in patients with a wide range of localisable neurological conditions. This suggests that the "lesion method" might be a valid approach to study the neurobiology of DP/DR. However, the fact that anxiety can trigger DP/DR makes it difficult to establish whether the presence of DP/DR in neurological patients is mainly determined by coexisting anxiety or by lesion location. To overcome this difficulty, we suggest the study of neurological phenomena, which although not considered as DP/DR, bear enough phenomenological resemblance with them as to warrant their use as models.

METHODS

One patient with "visual hypoemotionality" and another with "hemiasomatognosia" are described in detail together with a selective literature review.

RESULTS

Complaints of patients with visual hypoemotionality are indistinguishable from those of patients with "visual derealisation". There is also a phenomenological overlap between "asomatognosia" and the symptom of "body alienation", which is a central feature of depersonalisation.

CONCLUSIONS

Phenomenological similarities between visual hypoemotionality and DR suggest that a disruption of the process by means of which perception becomes emotionally coloured may be an underlying mechanism in both conditions. Likewise, phenomenological overlaps with asomatognosia suggest that DP might result from parietal mechanisms disrupting the experience of body ownership and agency. These findings give validity to the notion that DP and DR may have distinct neurobiological mechanisms.

Depersonalization disorder: thinking without feeling

Patients with depersonalization disorder (DP) experience a detachment from their own senses and surrounding events, as if they were outside observers. A particularly common symptom is emotional detachment from the surroundings. Using functional magnetic resonance imaging (fMRI), we compared neural responses to emotionally salient stimuli in DP patients, and in psychiatric and healthy control subjects. Six patients with DP, 10 with obsessive-compulsive disorder (OCD), and six volunteers were scanned whilst viewing standardized pictures of aversive and neutral scenes, matched for visual complexity. Pictures were then rated for emotional content. Both control groups rated aversive pictures as much more emotive, and demonstrated in response to these scenes significantly greater activation in regions important for disgust perception, the insula and occipito-temporal cortex, than DP patients (covarying for age, years of education and total extent of brain activation). In DP patients, aversive scenes activated the right ventral prefrontal cortex. The insula was activated only by neutral scenes in this group. Our findings indicate that a core phenomenon of depersonalization--absent subjective experience of emotion--is associated with reduced neural responses in emotion-sensitive regions, and increased responses in regions associated with emotion regulation.

Basal activity of the hypothalamic-pituitary-adrenal axis in patients with depersonalization disorder

Depersonalisation disorder may occur during severe anxiety or following a traumatic event, suggesting a possible role of stress hormones. This study investigated basal activity of the hypothalamic-pituitary-adrenal (HPA) axis in patients with depersonalisation disorder. Salivary cortisol levels were measured at four time points over 12 h in patients with depersonalisation disorder (N=13), major depressive disorder (MDD, N=14) and healthy controls (N=13). Beck Depression Inventory scores were significantly higher in depersonalised subjects than controls, while MDD subjects demonstrated higher scores than both groups. Basal cortisol levels of depersonalised subjects were significantly lower than those of MDD subjects but not healthy controls. These results point to reduced basal activity of the HPA axis in depersonalisation disorder. This pilot study supports the distinction between depersonalisation disorder and major depressive disorder which should be examined in a larger sample.

Visual imagery and depersonalisation

Twenty-eight people diagnosed with depersonalisation disorder (DD) were assessed using self-report measures of imagery ability in relation to a range of symptoms and in comparison with age- and sex-matched controls. It was found that symptoms of depersonalisation as well as other dissociative symptoms and depressed mood correlated with impaired ability to generate visual images. This was particularly evident with images pertaining to the self and other people as opposed to objects. A subgroup of 10 patients was tested on a neuropsychological battery of visual perception tests and found to be unimpaired compared with normal controls and patients with obsessive compulsive disorder, despite subjective impairments in imagery and high symptom scores. The findings add further weight to the distinctions made between imagery and perceptual processes.

The phenomenological stability of depersonalization: comparing the old with the new

The view that depersonalization is a stable syndrome became well established during the first half of the 20th century. Current operational definitions restrict depersonalization to the experience of unreality. This is likely to neglect clinical features of potential neurobiological relevance. By using the year 1946 as the dividing line, 200 cases of depersonalization disorder reported in the medical literature since 1898 were divided into two historical groups (1 and 2). The groups were then compared in terms of 18 phenomenological variables with a sample of 45 prospective cases of DSM-IV depersonalization disorder (group 3 or gold standard). Groups 1 and 2 differed in terms of their symptom profile, but the highest frequency that symptoms achieved in either group did not differ from the rates identified in group 3. A core of (invariable) symptoms, including emotional numbing, visual derealization, and altered body experience, was present throughout. These high rates of spontaneous reporting in all three groups may be explained by the fact that they all are accompanied by specific distress. With the exception of heightened self-observation and altered time experiencing, all other symptoms were significantly lower in group 2. The results suggest that the phenomenology of depersonalization has remained stable over the last 100 years. Our study found differences in frequency for some symptoms, but these are likely to have resulted from reporting biases, themselves governed by changing theoretical views. Clinical descriptions became poorer as the present is approached. This cannot be solely explained on the basis of empirical progress, and it is likely that theoretical biases also play a role. Because the neurobiological relevance of the symptoms of depersonalization remains unknown, it makes sense to continue collecting as many symptoms as possible, thereby avoiding both biased selection or premature closure.

Effects of ispaghula husk and guar gum on postprandial glucose and insulin concentrations in healthy subjects

OBJECTIVE

The aim of this study was to evaluate, under the same experimental conditions and in the same subjects, the effects of ispaghula husk and guar gum on postprandial glucose and insulin concentrations in healthy female subjects.

DESIGN

An oral glucose load with and without fiber was administered in the morning after an overnight fast. The study of the fiber effect was planned according to a randomized and cross-over design.

SETTING

The study was performed at the Department of Pharmacology, Toxicology and Nursing at the University of León (Spain).

SUBJECTS

Ten healthy female volunteers aged 30-48 y with normal body mass indices participated in this study.

RESULTS

A significant decrease in mean serum insulin concentrations was observed from 30 to 90 min in the presence of both fibers. The area under the insulin curve was significantly reduced by 36.1% for ispaghula husk and 39.4% for guar gum. The area under the glucose curve was reduced by 11.1% (significant difference) for ispaghula husk and 2.6% for guar gum (no significant difference).

CONCLUSIONS

According to the results obtained in this study, the administration of ispaghula husk may be beneficial due to its ability to reduce glucose postprandial concentration and especially insulin requirements. Individualization of the treatment would be advisable due to large individual variations observed in glycemic and insulinemic postprandial responses.

Laparoscopic pancreatic surgery in patients with neuroendocrine tumours: indications and limits

Laparoscopic pancreatic procedures are still at an evaluation stage with regard to their indications and techniques. Between January 1998 and December 2000, 13 patients with endocrine pancreatic tumours - 11 insulinomas and 2 non-functioning tumours-underwent laparoscopic surgery, laparoscopic ultrasonography being used in all the patients. Enucleation was performed in five patients. The operative time was 2-3 hours. Distal pancreatectomy was performed in six patients with insulinomas, and spleen preservation with intact splenic vessels was feasible in five. Splenectomy was necessary in one patient for technical reasons. Laparoscopic distal pancreatectomy with splenic vessel preservation was performed in two patients with a large (6 and 8 cm) non-functioning tumour. The mean operative time for all the patients undergoing distal pancreatectomy was 4 hours, ranging from 3 to 5 hours. A pancreatic fistula occurred in three patients after tumour enucleation and in two patients after distal pancreatectomy; the mean hospital stay for all patients was 5 days. Enucleation guided by laparoscopic ultrasonography thus allows safe tumour dissection and excision, laparoscopic distal pancreatectomy also being feasible and safe. Splenic salvage with splenic vessel preservation is technically possible. The laparoscopic approach allows a shorter hospital stay and an earlier return to normal activities.

Persistent hypercalcitoninemia in patients with medullary thyroid cancer: a therapeutic approach based on selective venous sampling for calcitonin

BACKGROUND

Persistent or recurrent medullary thyroid carcinoma (MTC) can be cured by microdissection of residual metastatic lymph nodes in the neck. Selective venous sampling can be used for localization. The aim of this study is to prospectively analyze our results with a therapeutic approach based on venous sampling, in patients with hyperthyrocalcitoninemia after thyroidectomy for MTC.

METHODS

Selective venous sampling for determination of stimulated calcitonin was obtained in all patients after performing a complete laboratory and imaging workup. Patients with a gradient between the suprahepatic vein and the superior vena cava underwent unilateral or bilateral extensive lymph node dissection. We used the gradient between the right and left jugular veins to decide which side of the neck to operate. Calcitonin levels were obtained after surgery and a pentagastrin test was performed one year later if basal levels remained normal.

RESULTS

Mean age of the five women with a neck gradient in the selective venous sampling who underwent neck exploration was 45 years. In all patients metastatic lymph nodes were found at the site suggested by the study. Mean positive/resected lymph nodes were 5/20. Postoperative basal and stimulated levels of calcitonin became normal in two patients at one year of follow up.

CONCLUSION

Selective venous sampling is useful to localize recurrent MTC.

Intra-muscular vidarabine therapy for polyomavirus-associated hemorrhagic cystitis following allogeneic hemopoietic stem cell transplantation

Hemorrhagic cystitis (HC) is a common complication following hemopoietic stem cell transplantation (HSCT), its incidence ranging from 7 to 52% of all patients. Late occurring HC frequently results from viral infections. We describe a patient who developed severe polyomavirus-associated HC, which responded dramatically to a single dose of intra-muscular vidarabine. Previous studies show an improvement in HC with vidarabine therapy, but to date only the intravenous route of administration has been described and responses described take from several days to weeks. This report confirms the safety and efficacy of vidarabine administered intramuscularly when used in patients with an adequate platelet count, thereby making its use feasible when intravenous vidarabine is not available.

Influence of two dietary fibers in the oral bioavailability and other pharmacokinetic parameters of ethinyloestradiol

Dietary fibers are widely used in hypoglycaemic, hypolipidemic, slimming diets. It is probable that their ingestion coincides with the oral administration of drugs and a modification of their pharmacokinetics can appear. In the present study, the influence of two soluble fibers (guar gum and psyllium) was evaluated on the pharmacokinetics of ethinyloestradiol (EE) when they were administered together to female rabbits via the oral route. Three groups of rabbits were used. All animals received 1 mg/kg of EE; this compound was administered alone in the control group and with 3.5 g of guar gum or psyllium in the other two groups. When guar gum was administered, there was a decrease in the extent of EE absorbed, but no change was observed in the rate of absorption. When psyllium was administered, the extent of EE absorbed increased slightly and the rate of absorption was slower.

The Cambridge Depersonalization Scale: a new instrument for the measurement of depersonalization

Existing self-rating scales to measure depersonalization either show dubious face validity or fail to address the phenomenological complexity of depersonalization. Based on a comprehensive study of the phenomenology of this condition, a new self-rating depersonalization questionnaire was constructed. The Cambridge Depersonalization Scale is meant to capture the frequency and duration of depersonalization symptoms over the 'last 6 months'. It has been tested on a sample of 35 patients with DSM-IV depersonalization disorder, 22 with anxiety disorders, and 20 with temporal lobe epilepsy. Scores were compared against clinical diagnoses (gold standard) and correlated with the depersonalization subscale of the Dissociation Experiences Scale (DES). The scale was able to differentiate patients with DSM-IV depersonalization disorder from the other groups, and showed specific correlations with the depersonalization subscale of the DES (r=0.80; P=0.0007). The scale also showed high internal consistency and good reliability (Cronbach alpha and split-half reliability were 0.89 and 0.92, respectively). The instrument can, therefore, be considered as valid and reliable, and can be profitably used in both clinical and neurobiological research.

Risk factors and context of men who physically abuse in Bogotá, Colombia

OBJECTIVES

The aim of this study was to identify risk factors for physical abuse caused by male perpetrators, as well as to describe the context of abuse and the role of the female partner in these cases in Bogotá, Colombia.

METHODS

Information from in-depth interviews of males reported to authorities for physical child abuse and their female partners (n = 45) was quantitatively and qualitatively analyzed and compared to to males and their female partners from the same neighborhood living with a child of the same gender and age (+/-3 years) as the abused child (n = 44).

RESULTS

Situations of abuse occurred more often on a weekday, in the afternoon or early evening hours, with the mother present, exceptionally involved substance abuse, and tended to be repetitive. Male subjects' lower level of education, stepfather status, perceived stress, substance abuse and mental illness, lack of social support, history of childhood physical abuse, negative perceptions, attributions and unrealistic expectations of the child's behavior were associated with abuse. Cases' female partners were more likely to have a lower occupational level, a higher frequency of dependent personality, a history of childhood physical and sexual abuse and be herself physically and emotionally abused by her spouse. At least three scenarios for abuse emerged from the analyses: "explosive" men, "abusive disciplinarians," and "children out of parental control."

CONCLUSIONS

Most of the findings are consistent with existing research despite the different social and cultural context. The different scenarios suggest the need to tailor preventive and rehabilitative interventions for abusers.

Studies in thoracic aortic graft infections: the development of a porcine model and a comparison of collagen-impregnated dacron grafts and cryopreserved allografts

OBJECTIVE

A porcine model of thoracic aortic graft infection was created, and various anatomic sites and the timing of inoculation of the graft to induce infection were investigated. Ultimately, the ability of cryopreserved allograft to resist infection was compared with that of collagen-impregnated Dacron graft.

METHODS

Yorkshire pigs (n = 16) underwent placement of an expanded polytetrafluoroethylene patch graft in the ascending aorta and the left atrial appendage (phase I). Eight animals were immediately given a 50-mL bolus (1 x 10(8) cfu/mL) of Staphylococcus aureus whereas the other 8 received the infusion 24 hours later. Animals were put to death 8 weeks later and the grafts were sterilely explanted and analyzed via microbiologic culture and standard histologic procedures for evidence of infection. The results displayed that the aortic graft and a delay of induced bacteremia of 24 hours were more reliable methods of producing infection. During phase II, 13 pigs were randomized to receive either a collagen-impregnated Dacron graft (n = 6) or a cryopreserved allograft (n = 7) in the ascending aortic position only and infusion of S aureus 24 hours after the operation. The experiment then proceeded to completion.

RESULTS

Phase I results displayed that use of an aortic graft and induced bacteremia 24 hours after the operation was a more reliable and reproducible method of producing infection. In phase II, graft infection was present in 38.5% (5/13) of animals, with only 16.7% (1/6) in the collagen-impregnated Dacron graft group and 57.2% (4/7) in the cryopreserved allograft group becoming infected. There was no significant difference between the collagen-impregnated Dacron graft and cryopreserved allograft groups in the incidences of thoracic aortic graft infections (P =.27, Fisher exact test).

CONCLUSIONS

This novel porcine model of thoracic aortic graft infection is a reproducible method for the investigation of thoracic aortic graft infections. The phase I study investigated the timing of the induced bacteremia and the most susceptible position of a graft. Phase II demonstrated that collagen-impregnated Dacron grafts are equivalent, if not superior, to cryopreserved allografts in resisting central vascular graft infections in the ascending aorta.

[Prospective study of the invasive strains of Streptococcus pneumoniae isolated in 16 hospitals in Cataluna, Spain]

BACKGROUND

The increasing penicillin resistance rates of Streptococcus pneumoniae led us to review the strains isolated from usually sterile sources during 1996 in 16 hospitals of Cataluña.

METHODS

A card was designed for the prospective collection of patients' data. Susceptibility to penicillin, cefotaxime and erytromicin, as well as serotypes, were studied.

RESULTS

237 S. pneumoniae strains were isolated from patients aged from one month to 95 years (19% younger than 5 years), 9.7% of adult patients being HIV antibodies carriers. Global penicillin resistance was of 35.4% (27.4% with minimal inhibitory concentration [MIC] between 0.1 and 1 microgram/ml and and 8.0% > 1 microgram/ml), but it was only of 25% in strains causing meningeal infections, and of 34.1% in those involved in respiratory processes. Paediatric patients less than five years old had a higher resistance rate (47.7%), as well as octagenarian ones (44.7%), but HIV+ patients had a lower rate (30.4%). 12.2% of strains (10% of meningeal ones) showed some degree of cefotaxime resistance but only five of them (none from meningeal origin) reached a MIC of 2 micrograms/ml. Global erythromicin resistance was 17.7% (17.1% in strains causing respiratory infections). Prevalent serotypes were 6, 9 and 14.

CONCLUSIONS

The high percentage of strains, mainly from paediatric patients, with diminished penicillin, cefotaxime and erythromicin susceptibility among those causing meningitis and respiratory infections, alerts of possible therapeutic failures if empiric treatments are established in infections produced by this microorganism. For this reason, nowadays it is necessary the routine study of the susceptibility of all pathogen strains of pneumococci. Most strains (208 out of 216) causing invasive disease in our area belong to serotypes covered by the present 23-valent vaccine.

Flashbulb memories and other repetitive images: a psychiatric perspective

The term "flashbulb memory" was used by Brown and Kulik in 1977 to refer to the vivid recollections that humans may have of events considered to be of particular significance to the individual or group. These memories are described as having a photographic quality and as being accompanied by a detail-perfect apparel of contextual information (weather, background music, clothes worn, etc.) pertaining to the time and place where the event was first known. They may even evoke emotions similar to the ones felt upon hearing the news. It has been suggested that flashbulb memories are formed by the activity of an ancient brain mechanism evolved to capture emotional and cognitive information relevant to the survival of the individual or group. Some of the original assumptions made by Brown and Kulik have since been challenged, but the phenomenon in question remains an important area of research. However, the latter is often marred by the fact that flashbulb memories are studied as if they were unique psychological events without parallel in clinical practice. Psychiatrists, however, should consider flashbulb memories as being members of a broad family of experiences that include drug flashbacks, palinopsia, palinacusis, posttraumatic memories, and the vivid and haunting memories experienced by subjects with some forms of mental disorder (e.g., phobias, panic attacks, obsessional disorder, phantom-limb phenomena, and depressive melancholia). All of these experiences share clinical features such as paroxysmal repetition, sensory vividness, a capacity to trigger emotions, dysphoria, and a tendency for the rememberer to shift from the role of actor to that of observer and for the reminiscence to become organized in a stereotyped narrative. Some of these clinical phenomena are discussed, and the suggestion is made that seeking phenomenological and neurobiological common denominators to all of these experiences may be a superior research strategy versus studying flashbulb memories alone.

Decreased excretion of nitrate and nitrite in essential hypertensives with renal vasoconstriction

Most hypertensive patients exhibit increased renal vascular resistance (RVR). This study was designed to investigate whether there exists any relationship between RVR and the production of nitric oxide (NO) in patients with essential hypertension. The study was performed in 49 non-treated patients with mild-to-moderate essential hypertension, and 20 age- and sex-matched normotensive subjects on a controlled sodium diet. Renal hemodynamics was measured in terms of the clearance of para-aminohippuric acid and inulin. Urinary excretion of nitrate and nitrite (NO3- plus NO2-) was determined as an index of NO production. As compared with normotensives, hypertensive patients exhibited higher (P < 0.001) RVR and lower (P < 0.05) urinary excretion of NO3- plus NO2-. With the 100% confidence (upper) limit of the normotensive population as a cut-off point, a subgroup of 30 hypertensives had an abnormally high RVR. The excretion of NO3- plus NO2- was lower (P < 0.005) in hypertensives with high RVR than in normotensives and the remaining hypertensives. No differences were found in the urinary excretion of NO3- plus NO2- between normotensives and hypertensives with normal RVR. Statistically significant associations were seen between diastolic blood pressure and RVR (r = 0.341, P < 0.05) and urinary excretion of NO3- plus NO2- (r = -0.387, P < 0.01) in all hypertensives. These results indicate that there is a subgroup (61%) of hypertensive patients with diminished urine levels of NO3- plus NO2- in which RVR is abnormally increased. Thus, it is suggested that in essential hypertension a diminished renal ability to produce NO by the endothelium may be involved in exaggerated renal vasoconstriction.

Prospective biochemical and scintigraphic evaluation of autografted normal parathyroid glands in patients undergoing thyroid operations

BACKGROUND

Parathyroid autotransplantation has been widely used in thyroid operations. Few studies have assessed the function of the autotransplanted glands. The aim of this study was to evaluate the success rate, pattern of biochemical function, and scintigraphic appearance of parathyroid autografts in patients undergoing thyroid operations.

METHODS

Twelve patients in whom 1 parathyroid gland was removed during thyroid operation were included. Glands were fragmented and autografted into individual pockets in the brachioradialis muscle of the nondominant forearm. Parathyroid hormone levels were measured in both arms the day of autotransplantation and 2 weeks and 1, 2, 3, and 6 months after operation. Serum calcium levels were also measured at each interval. Sestamibi scanning was performed 6 months after operation in 7 patients.

RESULTS

All patients were women with a mean age of 50 +/- 15 years. Serum calcium levels were normal during follow-up. A gradient of parathyroid hormone level of 1.5 or greater between the autotransplanted and nontransplanted arm was found in 10 patients. Isotope uptake at the site of the parathyroid autotransplant was demonstrated in the 7 patients evaluated.

CONCLUSIONS

Biochemical function of autotransplanted normal parathyroid tissue was documented in 83% of the patients. Sestamibi scintiscans were able to identify the autotransplanted tissue.

Depersonalization: neurobiological perspectives

Depersonalization remains a fascinating and obscure clinical phenomenon. In addition to earlier Jacksonian neurobiological adumbrations, and conventional psychodynamic accounts, views started to be expressed in the 1930s that depersonalization might be a vestigial form of behavior, and since the 1960s that it might be a phenomenon related to the temporal lobe. Recent advances in the neurobiology of the limbic system, and the application of Geschwind's concept of disconnection in the corticolimbic system, have opened the possibility of developing testable models. This paper includes a review of these ideas and of the clinical features of depersonalization, particularly of its emotional changes, suggesting that they are important for the neurobiological understanding of depersonalization. It also draws attention to clinical similarities between the experiential narratives produced by patients suffering from depersonalization and those with corticolimbic disconnections. On the basis of this, a new model is proposed according to which the state of increased alertness observed in depersonalization results from an activation of prefrontal attentional systems (right dorsolateral prefrontal cortex) and reciprocal inhibition of the anterior cingulate, leading to experiences of "mind emptiness" and "indifference to pain" often seen in depersonalization. On the other hand, a left-sided prefrontal mechanism would inhibit the amygdala resulting in dampened autonomic output, hypoemotionality, and lack of emotional coloring that would in turn, be reported as feelings of "unreality or detachment."

Bioavailability of levamisole after intramuscular and oral administration in sheep

AIMS

To determine the bioavailability of levamisole in sheep.

METHODS

Levamisole was administered to three groups of six Merino sheep orally and intramuscularly at three dose levels of 5, 7.5 and 10 mg/kg. There was a washout period of 1 week between treatments. Blood samples were collected by jugular venepuncture and plasma was separated immediately by centrifugation and stored at 20 degrees C until analysed. The levamisole concentration in plasma was determined by high performance liquid chromatography with a U.V. detection method. Individual plasma levamisole concentration-time data were analysed using the compartmental method.

RESULTS

The values obtained for k(a), C(max), t(max) and F show a moderate rate and extent of absorption after oral administration of levamisole while, after intramuscular administration, these values demonstrate a high rate and extent of absorption of levamisole. The intramuscular bioavailability was higher than the oral bioavailability (rate of absorption three-fold faster, extent of absorption 25-33% higher and C(max) two-fold higher). The Friedman test involving dose and route of administration showed that the route of administration affects k(a), C(max), t(max) and F; significant differences were found in these parameters.

CLINICAL RELEVANCE

On the basis of these data, the recommended routes for the administration of levamisole in sheep are oral for gastro-intestinal nematodiasis and intramuscular for extragastric nematodiasis.

Influence of two commercial fibers in the pharmacokinetics of ethinylestradiol in rabbits

Fiber formulations are used in human nutrition owing to their beneficial properties for health. It is probable that ingestion of fiber coincides with the oral administration of drugs, and a modification of its oral absorption, and therefore of its pharmacokinetics, can appear. In the present study, the compartmental and noncompartmental pharmacokinetic parameters of ethinylestradiol (EE) in rabbits after oral administration were determined. It was also studied whether the presence of two different fiber formulations [A, wheat bran (76.5%), fruit fiber (12%) and guar gum (2%) and B, Plantago ovata seeds (65%) and P. ovata seed cuticles (2.2%)] in the gastrointestinal tract modified the pharmacokinetics of EE when administered at the same time. Three groups of rabbits were used: control, fiber A and fiber B. The animals in all three groups received 1 mg/kg b. wt. EE. The estrogen was administered alone in the control group and in the presence of 4 g of fiber A and fiber B, respectively, in the other two groups. After compartmental (two-compartment open model) and noncompartmental analyses of plasma concentrations, statistical analysis revealed that the presence of fiber (both A and B) decreased between 29% and 35% the extent of EE absorbed (represented by the pharmacokinetic parameters area under the curve and the maximum plasma concentration) without affecting the rate of the absorption process (represented by the time to reach maximum concentration and the absorption rate constant).

[Neonatal infection by Streptococcus agalactiae. Multicenter study in the area of Barcelona, Spain]

BACKGROUND

Streptococcus agalactiae or streptococcus group B (SGB) is the main etiologic agent of early neonatal sepsis. A multicenter study was performed with the aim of determining the incidence and characteristics of this disease in our medium and contribute the design of an adequate prevention protocol.

METHODS

Ten hospitals and two primary health care centers were implicated in the study; 103 microbiology confirmed episodes of SGB neonatal sepsis (blood and/or LCR positive) were reported from 1994 to 1996.

RESULTS

The incidence of early SGB neonatal sepsis was 1.48/1,000 live births with a mortality of 8.7%. The cultures, for detecting the state of the SGB carrier were performed in only 26 (25%) of the patients. At least one of the factors described for risk of perinatal SGB infection was observed in 46% of the mothers, with the most frequent being prolonged amniorrhea (26%), intrapartum fever (17%), and early delivery (14%). At the time of delivery only 10.7% of the mothers received endovenous antibiotherapy.

CONCLUSIONS

From these results the following recommendations have been made: a) detection of SGB carriers by the systematic practice of blood cultures in the last weeks of gestation and b) the administration of intrapartum antibiotic prophylaxis in both early births (< 37 weeks) and in all the SGB carriers should be undertaken. With these measures we aim to decrease the neonatal infections by streptococcus group B.

Organochlorine pesticide residues in muscle tissue of rainbow trout, Oncorhynchus mykiss, taken from four fish farms in León, Spain

Levels of nine organochlorine pesticides (lindane, heptachlor epoxide, aldrin, dieldrin, endrin, o,p'-TDE, p,p'-TDE, p,p'-DDE and p,p'-DDT) were determined in muscle samples of rainbow trout, Onchorhynchus mykiss, collected from four fish farms in the province of León, in the north-west of Spain (Europe). The highest incidence percentage was for lindane (67.5%) and heptachlor epoxide (55.0%). Organochlorine residue levels detected contributed slightly to acceptable daily intakes (ADIs) established by the Food and Agriculture Organization of the United Nations and the World Health Organization (lindane 0.22-2.3%; sigma DDT 0.05-0.46%; heptachlor epoxide 10.0-71.4% and sigma dieldrin 16.7-33.3% assuming 300 g of trout muscle as a mean daily intake). The highest concentration found was for heptachlor epoxide (0.043 microgram/g).

Depersonalization: a conceptual history

As with other clinical phenomena, the historical analysis of the term, concepts and behaviours involved in the construction of 'depersonalization' should provide researchers with an essential frame for its empirical study. Before the term was coined in 1898, and under a variety of names, behaviours typical of 'depersonalization' were reported by Esquirol, Zeller, Billod, and Griesinger. The word 'depersonnalisation, derived from a usage in Amiel's Journal intime, was first used in a technical sense by Ludovic Dugas. The new disorder has since been explained as resulting from pathological changes in the sensory system, memory, affect, body image and self-experience. During the 1930s, evolutionary views became popular, particularly in the work of Mayer-Gross. The unclear conceptual boundaries of depersonalization still invite confusion and often enough fragments of what used to be its core-behaviour are used to diagnose the disorder. Depersonalization has of late become subsumed under the dissociative disorders. The definitional instability of the latter, however, has caused further complications to the study of depersonalization. It is recommended that the term is used to refer only to the original core-behaviour as this has shown adequate stability.

Plasma protein binding of levamisole in several species

The binding of levamisole to total plasma proteins of 6 animal species was determined in vitro by equilibrium dialysis. The percentage of bound drug protein was independent of levamisole concentration within the range studied, 5-50 micrograms/ml (ANOVA). Levamisole was bound to a low extent to plasma proteins of each animal species (19.40-25.91%). There were significant differences in the extent of levamisole binding among species (ANOVA). Owing to the low degree of protein binding and the high volume of distribution of levamisole, the variations in protein binding due to different factors would not be of major clinical importance in its therapeutic application.

[Anaplastic carcinoma of the thyroid at the Instituto Nacional de la Nutrición Salvador Zubirán]

BACKGROUND

Anaplastic thyroid carcinoma (ATC) is a highly aggressive tumor with a median survival rate of 6 months.

AIM

To analyze presentation, treatment, morphology, immunohistochemistry, and nuclear DNA analysis of a cohort of patients with ATC.

PATIENTS AND METHODS

Twelve patients with ATC (11 female) with a mean age of 65 years were seen at our hospital from 1970-1995. The data were obtained from the clinical records and the morphology, immunohistochemic studies and DNA pattern were performed in slides obtained from archival specimens.

RESULTS

Previous or coexisting thyroide disease was documented in 10 patients (9 multinodular goiters and one Grave's). The most frequent presentation was a rapidly growing tumor associated with dysphagia, cervical pain, hoarseness and dyspnea. A cold thyroid nodule was detected by thyroid scan in 10 patients. The most frequent subtype was the spindle cell variety. Papillary thyroid carcinoma coexisted in eight cases, two of them corresponded to the tall cell variant. Reactivity for S-100 protein and vimentin was studied in six patients: all were positive for S-100 protein and vimentin, 5/6 for epithelial membrane antigen, half for carcinoembriogenic antigen, 2/6 for thyroglobulin and calcitonin, and one for neuronal specific enolase. These six tumors showed a diploid DNA pattern. Tumor resection was achieved in 2/11 and none survived six years after diagnosis.

CONCLUSIONS

ATC is a highly aggressive tumor coexisting with thyroid pathologies. Spindle cell variant is the most frequent with positive reactivity for S-100 protein, vimentin and epithelial membrane antigen. Most tumors have a diploid DNA content.

Pharmacokinetics of levamisole in sheep after intravenous administration

The pharmacokinetics of levamisole at doses of 5, 7.5 and 10 mg/kg were determined after its intravenous administration to eighteen healthy Merino sheep. Using compartmental analysis, the disposition of the drug best fitted a two-compartmental open model. The mean values for the compartmental volume of distribution at steady state (Vss) were 2.034 +/- 0.23 I, 2.347 +/- 0.720 and 2.001 +/- 0.367 I/kg for each dose, respectively, and values obtained using the statistical moment theory were 2.141 +/- 0.269,2.390 +/- 0.536 and 2.140 +/- 0.345 l/kg for each dose, respectively. There were no dose-related differences (one-way ANOVA) in the constants describing distribution and elimination phases (alpha and beta) or Vss, but significant differences were detected in the total body clearance (Cl) and the area under the plasma concentration-time curve (AUC). After non-compartmental analysis, no significant differences were found when the parameters lambda (the linear terminal slope) and Vss were compared, but significant differences were detected in Cl and AUC. There were no significant differences between the values obtained using the compartmental and non-compartmental analysis when lambda -beta, Cl, Vss, and AUC were compared.

Study of the pharmacokinetic interaction between ethinylestradiol and amoxicillin in rabbits

Several antibiotics have been implicated in oral contraception failure when they are administered at the same time as the oral contraceptive (OC) pill. In the present paper, a study about amoxicillin-ethinylestradiol (EE2) pharmacokinetic potential interaction was studied. Two rabbit groups were utilized, the first group received amoxicillin (10 mg/kg) and EE2 (30, 50 and 100 micrograms/kg, respectively), both by intravenous (i.v.) route. The second group received amoxicillin (oral route, 10 mg/kg/day) and EE2 (i.v. route, 100 mu/kg) on day 1, 4 and 8 of antibiotic treatment, respectively. After compartmental (two-compartment open model) and non-compartmental analysis of plasma concentrations, the statistical study (ANOVA p < or = 0.05) revealed that the presence of amoxicillin did not modify the EE2 distribution and elimination pharmacokinetic parameters (by comparison with those obtained in a previous study where EE2 was administered alone). There also were no significant differences with the time of amoxicillin oral treatment.

Vasoconstriction of the afferent arteriole and defective renal synthesis of nitric oxide in essential hypertension

This study was designed to investigate whether some relation exists between afferent arteriolar resistance (AAR) and the renal production of nitric oxide (NO) and prostacyclin (PGI2) in 21 patients with untreated essential hypertension and 20 normotensive controls. All subjects were studied in conditions of an unlimited Na+ diet both basally and after a four-hour amino acid infusion. AAR was calculated using Gomez's equations. Renal production of NO and PGI2 were assessed by radioimmunoassay of the urinary excretion of cGMP and 6-keto-PGF1 alpha, respectively. Baseline AAR was higher (P < 0.01) in hypertensives than in normotensives. The baseline urinary excretion of 6-keto-PGF1 alpha and cGMP were similar in the two groups of subjects. AAR diminished (P < 0.005) in normotensives and remained unchanged in hypertensives after amino acid infusion. Urinary excretion of 6-keto-PGF1 alpha was increased similarly in the two groups of subjects after infusion. Urinary excretion of cGMP remained unchanged in normotensives and decreased by 31% in hypertensives after infusion. These findings suggest that afferent vasoconstriction present in hypertensive patients is unresponsive to the vasodilatory manoeuvre of amino acid infusion. This lack of response may be due to a defective renal synthesis of NO in these patients.

Pharmacokinetics of ethinyloestradiol in rabbits after intravenous administration

The pharmacokinetics of ethinyloestradiol (EE2) after intravenous administration of 30, 50 and 100 micrograms.kg-1 was investigated in rabbits. A high-performance liquid chromatographic (HPLC) method with electrochemical (EC) detection was used to measure EE2 in plasma samples in order to avoid the interferences of natural oestrogens. After compartmental analysis, the disposition of EE2 was well described by a two-compartmental open model with mean values of: alpha = 0.3448 +/- 0.2922, 0.1965 +/- 0.1755, 0.3058 +/- 0.1225 min-1, and beta = 0.0137 +/- 0.0018, 0.0140 +/- 0.0065, 0.0198 +/- 0.0066 min-1, for the three doses studied, respectively. There were no dose-related differences (ANOVA, P < 0.05) in a, b or Vss, but significant differences were detected in clearance (90.9 +/- 18.7; 80.6 +/- 17.6; 116.3 +/- 21.5 ml.min-1.kg-1) between the 100 micrograms.kg-1 group and lower dose groups. The AUC increased significantly with the doses (341.7 +/- 67.1; 645.8 +/- 143.9; 892.2 +/- 211.9 ng.min.ml-1). After non-compartmental analysis there were no significant differences in lambda, MRT or Vss as a function of dose, but these differences were significant when Cl or AUC were compared. There were no significant differences in AUC or Cl values obtained by compartmental and non-compartmental analysis.

Organochlorine pesticide residues in bovine milk from Leon (Spain)

Residue levels of the organochlorine pesticides (alpha-HCH, lindane, heptachlor-epoxide, aldrin, endrin, dieldrin, o,p'-TDE, p,p'-TDE, p,p'-DDE and p,p'-DDT) were determined in raw bovine milk and compared with the maximum levels allowed by the European Union (EU) in these foods. The highest incidence percentage of the ten insecticides measured was for lindane, followed by alpha-HCH and aldrin. Moreover, the highest mean residue level was for alpha-HCH. None of the samples analyzed exceeded the maximum levels allowed by the EU.