[Spontaneous bacterial peritonitis: a comparative study of 2 methods of ascitic fluid culture]

The sensitivity in the diagnosis of spontaneous bacterial peritonitis of ascitic fluid inoculation in blood culture bottles has been compared with the conventional method. We have analyzed 74 positive ascitic fluid cultures from 64 patients, the samples being processed by both techniques simultaneously. While all the ascitic fluid cultures performed by inoculation in blood culture bottles were positive, in only 42 from the 74 conventional cultures (56, 75%) bacterial growth was detected (p less than 0.001). Nineteen bacterascites were diagnosed by inoculation in blood culture bottles and 10 by the conventional method (p = NS). Gram stain was only positive in 3 spontaneous bacterial peritonitis (6%). We conclude that ascitic fluid inoculation in blood culture bottles improves significantly the sensitivity of the microbiological diagnosis of spontaneous bacterial peritonitis, without increasing the diagnosis of bacterascites.

A randomized multicentric study comparing alternating combination chemotherapy (VCMP/VBAP) and melphalan-prednisone in multiple myeloma

Between January 1985 and December 1988, 386 patients with multiple myeloma were randomized to receive either MP or combination chemotherapy based on alternating cycles of VCMP and VBAP. The major prognostic parameters did not differ significantly between both treatment groups. A significantly higher proportion of objective responses was observed with combination chemotherapy as compared to MP (47.8 vs 32.2, P = 0.01). The median survival for all patients was 33.5 months. So far no significant differences were found when comparing the survival curves from both groups of patients. However, the median survival of MP-treated patients is 26.8 months, whereas the median survival of patients receiving VCMP/VBAP has not yet been reached. The definitive analysis must await the evaluation of all patients entered into the study and a longer follow-up time.

[The training of the internist]

A critical situation surrounds Internal Medicine and the training of internists. The crucial role of Internal Medicine as an integrating discipline in clinical medicine and its relationship with primary care medicine and the specialties is analyzed. The goals of a training program for general internists and specialists are described. The scope of knowledge, skills and attitudes as well as the general training necessary to become an internist are summarized.

[Usefulness of laparoscopy as a second-look method in neoplasms of the ovary]

The usefulness of second-look laparoscopy in the follow-up of ovarian cancer is evaluated. This procedure has been included in the protocol for the treatment of these tumors. During the period 1980-1987 a total of 3038 laparoscopies were performed; 205 (7%) were for ovarian cancer. We present the results of 72 explorations in 52 patients; after surgery and chemotherapy all of them were in complete remission. 44 explorations were second-look laparoscopy and 28 third-look laparoscopy. All the examinations were done under local anesthesia. There were two failures due to the presence of adhesions secondary to the previous surgery which prevented the pneumoperitoneum. In 35 (48.6%) explorations a neoplasia was found and a laparotomy was avoided. There were 31% (4/13) false negative in second-look laparotomy post-laparoscopy. The correlation between gross and microscopic findings was excellent. There were no complications in spite of the previous abdominal surgery. We recommend second-look laparoscopy in patients under treatment of ovarian cancer which in our experience avoided laparotomy almost in half of the cases; no complications were observed and the procedure was well-tolerated.

Effects of acute valproate administration on carnitine metabolism in mouse serum and tissues

Carnitine concentrations in serum, liver, kidney, muscle and heart were determined 30 min, 2 hr and 4 hr after administration of single 50 mg/kg doses of valproic acid (VPA) or octanoic acid (OTA) of fasting mice. Half an hour post-administration (p.a.) of VPA, free carnitine concentrations were smaller than in controls in serum, liver, kidney and heart. Four hr p.a., the effects of VPA had disappeared from all the carnitine sources, which now had concentrations that were not significantly different from those of controls. The effects of OTA are different from, and sometimes the opposite of, those of VPA, showing that the effects of VPA are specific to it. Hyperammonemia, on the other hand, was greatest 4 hr p.a. of VPA. These findings show that the effect of VPA on carnitine metabolism is immediate but transient, and accordingly suggest that the carnitine deficiency observed in patients under prolonged treatment with VPA-containing anticonvulsants must be due to a more complex mechanism than direct interaction between carnitine and VPA.

Ultrasonic patterns observed in hepatic metastases from breast carcinoma: diagnosis and evolution

A retrospective analysis was made of 78 patients presenting breast neoplasm with hepatic metastases confirmed by ultrasound. Clinical hepatomegaly was present in 61%. The serum glutamic-oxaloacetic transaminase (SGOT) was elevated in 72%, the serum glutamic-pyruvic transaminase (SGPT) in 56%, the serum alkaline phosphatase (Aph) in 86%, and the gamma-glutamil transpeptidase (GGT) in 76%. A hypoechogenic multiple nodular pattern (HMN) was observed in 69%, a diffuse hypoechogenic pattern (DH) in 15%, and a mixed multiple nodular pattern (MMN) in 11%. No single nodular pattern was presented in any patient. The univariate analysis showed a better survival rate in patients with a mixed pattern (mean 11 months, range 1-29 months) (p = 0.027). No significant differences were observed regarding the remaining patterns, age, presence or not of hepatomegaly, or altered enzymatic values.

[The Ionescu-Shiley bioprosthesis in the aortic position. Medium to long-term evaluation]

From August 1977 through October 1984, 241 patients underwent aortic valve replacement with the Ionescu-Shiley prosthesis. The average age was 50.8 years (range 15 to 78). Aortic valve replacement was performed alone in 121 patients (50.2%) and with associated surgery in 120 (49.8%). Cumulative duration of follow-up was 1,260.08 patient-years, with a mean follow-up of 5.32 years per patient. Five patients were lost to follow-up. There were 26 hospital deaths and 15 late deaths (1.19% per patient-year). The expected 10.5 year actuarial survival rate was 82 +/- 2.9%. Twelve thromboembolic episodes occurred in 7 patients (7 central and 5 peripheral). The linearized thromboembolic rate was 0.95% per patient-year: 0.32% for patients with isolated aortic valve replacement and 0.63% for patients with concomitant surgery. Freedom from thromboembolic events at 10.5 years was 78 +/- 12%. Structural valve failure was found in 24 patients (1.9% per patient-year) with an actuarial rate of freedom for primary tissue failure of 72.6 +/- 6.1% at 10.5 years. Reoperation was required in 39 cases (3.09% per patient-year) due to primary tissue failure (n:24), paravalvular leak (n:7), infective endocarditis (n:6) and valve thrombosis (n:2). In conclusion, this pericardial bioprosthesis has demonstrated an adequate performance at mid and long-term follow-up, but somehow less satisfactory than previously reported.

[The Mitroflow bioprosthesis. Results after 6 years]

From March 1982 through December 1986, 139 Mitroflow pericardial heart valves were utilized in 129 patients. There were 69 males and 60 females, with an average age of 55.2 years (range 26 to 74 years). Eighty-nine patients underwent isolated aortic valve replacement, 27 isolated mitral valve replacement, three isolated tricuspid valve replacement and ten mitral-aortic valve replacement. In 20.9% additional cardiac surgery was performed. Maximum follow-up was 6 years with a mean of 43.9 months. The cumulative follow-up was 491 patients/year. Overall hospital mortality was 1.6% (2 cases). There were 3 late deaths in this series (2.4%). The linearized incidence of late mortality was 0.49% per patient/year. The survival actuarial curve was 96% +/- 1.8. The incidence of thromboembolism was 1.22% per patient/year, and the actuarial thromboembolism-free rate was 93% +/- 2.7. Three patients developed primary tissue failure of the Mitroflow valve in the mitral position. The linearized incidence of primary tissue failure was 0.73% per patient-year and the actuarial freedom from primary tissue failure was 95% +/- 3.2%. A total of 4 patients underwent reoperation (0.49% per patient/year). In conclusion, the clinical performance of the Mitroflow pericardial heart valve at medium-term follow-up is satisfactory; however a significant number of early primary tissue failures have already occurred in the mitral position.

[Tobacco consumption in a group of physicians of the V Valparaiso Region (Chile)]

We surveyed 174 physicians from the Valparaiso area regarding smoking habits. 25% were smokers and 75% were not, among them 103 exsmokers (70%). A slightly higher, but not significant percentage of women smokers was observed. Compared to the general population in that area the percentage of physician smokers is significantly lower. The latter show a greater tolerance to smoking habit among their family and patients. Most doctors surveyed were not impressed by the anti-smoking campaigns of health authorities.

[Granulocytic sarcoma of the base of the skull in chronic myeloid leukemia]

A 54 years old patient with Ph' negative chronic granulocytic leukaemia is reported, who presented rapidly progressive multiple cranial nerve palsies. A cerebral CT scan showed an invasive tumoral disease on the base of skull. Histologic examination of this mass was diagnostic for granulocytic sarcoma, which was the presentation form of an extramedullary blastic crisis. The general characteristics of granulocytic sarcoma are commented, special attention being paid to its appearance in the course of chronic granulocytic leukaemia.

[Long-term experience with flexible mitral annuloplasty]

Reconstructive surgery of the mitral valve is nowadays generally accepted to be a valid alternative to replacement. There is however little information on the long term stability of these techniques and specially the incidence of reoperation. In order to study this question all patients who had a Durán flexible ring annuloplasty performed between january 1975 and december 1976 were reviewed up to december 1987. Eighty seven flexible rings were placed in 85 patients. Aortic and/or tricuspid surgery was simultaneously performed in 44.8% of the patients. There were 2 hospital deaths (2.3% ) and 3 late deaths (3.5%). Ten patients were lost to follow up, all within 2 years after surgery. There were 18 thromboembolic events (11 central and seven peripheral) with one death. Thirteen patients required reoperation (17.8%) In 11 the valve was replaced and a new flexible ring annuloplasty was done in two, without mortality. The causes for reoperation were regurgitation in eight (10.9%) and stenosis in five (5.8%). When the lesion was regurgitant the average interval between operations was 20.6 months, and when stenotic of 87.8 months. It can be concluded that reconstructive surgery of the mitral valve, in this predominantly rheumatic group of patients, has an incidence or reoperation close to 18% at 12-13 years follow up.

Molecular cloning of a Drosophila potential Z-DNA forming sequence hybridizing in situ to a developmentally regulated subdivision of the polytene chromosomes

We describe the selection of a group of plasmids with potential to form Z-DNA, from libraries of Drosophila hydei nuclear DNA using anti Z-DNA monoclonal (22) or polyclonal (10c) antibodies. The supercoiled closed circular forms of most of the selected recombinant plasmids from the 10c Z-DNA library show affinity to the polyclonal 10c antibody as indicated by DNA binding assays. One of these plasmids, pF17, was selected for further study. The insert in this plasmid adopts the Z conformation at bacterial supercoiled density. Analysis of deletion plasmids indicates that a Z-epitope is located within a short fragment of the insert in which 3 GC repetitions are found. The Drosophila DNA insert in pF17 hybridizes in situ with locus 4-75C1-2 of the polytene chromosomes, a locus whose transcriptional activity is developmentally regulated during the third instar.

Time-dependent rheological behaviour of blood flow at low shear in narrow horizontal tubes

Magnitude and time-dependence of the effects of red cell aggregation and sedimentation on the rheology of human blood were studied during low shear (tau W 2.5 to 92 mPa) flow through horizontal tubes (ID 25 to 105 microns). Immediately following reduction of perfusion pressure to a low value the red cell concentration near the tube walls decreases as a result of red cell aggregation. This is associated with a transient increase of centerline velocity. Simultaneously, sedimentation begins to occur and eventually leads to the formation of a cell-free supernatant plasma layer. Time-course and extent of this sedimentation process are strongly affected by wall shear stress variation, particularly in the larger tubes. At the lower shear stresses, centerline velocity decreases (flow resistance increases) with time following the initial acceleration period, due to sedimentation of red cells. This is followed by a further increase of resistance caused by the elevation of hematocrit occurring because of the reduction of cell/plasma velocity ratio. The time dependence of blood rheological behaviour under these flow conditions is interpreted to reflect the net effect of the partially counteracting phenomena of sedimentation and red cell aggregation.

[Comparative study on the clinico-serologic course of acute hepatitis B and hepatitis B with delta co-infection]

The clinical and serological course of 35 instances of hepatitis B (22 hepatitis B alone and 13 with delta co-infection) was comparatively and prospectively studied for a mean follow-up period of 7.19 +/- 2.69 months. There were no significant differences between the clinical presentation and course between both types of patients. There were not, either, outstanding differences in the mean bilirubin and transaminase levels between both types of hepatitis, although the patients with delta co-infection initially showed a more pronounced cholestatic pattern than did patients with hepatitis B alone (p less than 0.05). In hepatitis B with delta co-infection, the serological markers of activity and/or replication of hepatitis B virus (HBV) showed an earlier serum clearance than in patients with hepatitis B alone, basically in relation with the "e" antigen of HBV. Serum measurement of hepatitis delta virus (HDV) antigen by means of ELISA was shown to be a high sensitivity test (69.23%) for the diagnosis of acute HDV hepatitis, which was carried out in an early stage since the development of symptoms.

Identification of a tumour factor inducing resistance to NK cell lysis

The mechanisms involved in the resistance or susceptibility of tumour cells to NK cytotoxicity are poorly understood. The role of different molecules on the target cell surface which could act as recognition elements by NK effectors has been postulated. However, there are also some tumour cell lines which release factors capable of inhibiting NK cytotoxicity. This paper presents a new factor (NK-RIF), produced and released by different tumour cell lines, making K562 resistant to NK lysis without affecting the cytotoxic function of NK effector cells. This soluble factor is shown to be thermolabile, non-dialyzable and to have a molecular weight of 36,000 daltons. It does not block the binding capacity of the target and effector cells, nor does it affect target susceptibility to LAK or cytotoxic T-cells.