[Transesophageal echocardiography in mitral prosthesis dysfunction: usefulness and limitations in the evaluation of mitral insufficiency]

This study was performed to test the usefulness of transesophageal echocardiography in the diagnosis and assessment of pathological mitral regurgitation in patients with mitral valve prostheses. Doppler color flow imaging by transesophageal echocardiography was compared to the transthoracic echocardiography and angiographic and surgical assessment. We analyzed the influence of the spatial configuration of the jet on the semiquantitative assessment of mitral regurgitation. We studied 71 patients with prostheses in mitral position which were submitted for transesophageal echocardiography examination. 51 of these patients were found to have a pathological prosthetic regurgitation that was confirmed in 21 cases by left ventriculography and in 4 during cardiac surgery. Transesophageal echocardiography Doppler color flow imaging identified a regurgitant jet in 31 patients (60.7%). There was complete agreement with the quantitative assessment of regurgitation by angiography or surgery in 36% of the cases. All patients with prosthetic insufficiency observed by angiography or during cardiac surgery were confirmed by transesophageal echocardiography. Complete agreement in grade of severity by transthoracic echocardiography was found in 84% of cases. There was a difference in grade of severity of mitral regurgitation in only 4 patients. Regurgitant jets were classified by transesophageal echocardiography color Doppler in two groups: free jets and impinging wall jets. 21 cases presented a free jet and 31 excentrically directed impinging wall jet of mitral regurgitation. There was complete agreement with hemodynamic assessment of severity in all patients with regurgitant free jets (11/11). In presence of jet wall there was understimation of mitral regurgitation in 28.5% (4/13).(ABSTRACT TRUNCATED AT 250 WORDS)

[Drug consumption in diabetes mellitus (III). Trends of hypoglycemic agents use and consumption in Tarragona, Catalonia, and Spain (1988- 1991). Group for the Study of Diabetes in Tarragona]

BACKGROUND

To analyze the evolution of the use of drugs in diabetes, the consumption of hypoglycemic medication in the province of Tarragona, the autonomic community of Catalonia and Spain as a whole, was studied. A qualitative evaluation of the tendencies of prescription, as an indirect index of quality in the health care to diabetics was performed.

METHODS

The sales of oral hypoglycemic medication (OH) and insulin (INS) were accounted for in the study environment between 1988-1991. To make consumption uniform a standardized unit of measure was used with defined daily doses (DDD)/1,000 inhabitants/day (Drug Utilization Research Group) of the different groups of drugs. Total consumption was obtained by a primary data source (Intercontinental Medical Statistics), and periodically compared with a secondary source (registry of public prescriptions within Tarragona).

RESULTS

A progressive increase in the consumption of hypoglycemic drugs was observed: 16.1 to 21.2 DDD/1,000 inhabitants/day (31%) in Spain; 17.7 to 19.8 (12%) in Catalonia and 19 to 23 (21%) in Tarragona. The increase in consumption of INS in Tarragona (43%) was greater than that of OH (12%). In Catalonia, it was much greater (INS: 23%, OH: 7%) and was parallel in Spain (36% and 30%, respectively). The OH/INS index decreased in Catalonia and Tarragona (1.3 and 1.9 in 1991) and remained practically constant (2.3-2.4) in Spain. A global decrease was produced in the consumption of slow insulins with a significant increase in intermediate, premixed and fast insulins. A growing increase in glibenclamide much greater than the remaining sulphonylureas was seen, in addition there was a persistent and low use (less than 1 DDD/100 inhabitants/day) of biguanides. Significative variations of medication consumption were registered according to the territory analyzed.

CONCLUSIONS

From 1988 to 1991 there has been an increase in the use of hypoglycemic drugs. The use of oral hypoglycemics has remained constant in relation to insulins in Spain and in Catalonia and, more so in Tarragona, there is a progressive inclination to the use of insulin. The evolution of consumption suggests important asymmetry in the quality of health care and denotes progression in the global educative offer to diabetics.

Treatment of melphalan-resistant multiple myeloma with vincristine, BCNU, doxorubicin, and high-dose dexamethasone (VBAD)

A total of 65 patients (35 male/30 female) with multiple myeloma primarily (33) or secondarily (32) resistant to melphalan and prednisone were treated with vincristine, carmustine (BCNU), doxorubicin, and high-dose dexamethasone (VBAD) at 4-week intervals. Among 60 evaluable patients the overall response was 36.6% (21.6% objective response plus 15% improvements). The response rate was significantly higher in primarily resistant patients than in those becoming resistant after a prior response (48.4 vs. 24.1%, P < 0.05). The median duration of response was 17.5 months. When survival of responders and non-responders were compared by the conventional method, a highly significant difference was observed (P < 0.001). However, using the Mantel and Byar procedure and the landmark method, only a trend for longer survival in the responders was registered. These results indicate that although VBAD is effective in at least one third of patients with advanced multiple myeloma resistant to melphalan, its impact on survival is limited.

[Utility of the examination of plasma-cell morphology in the study of multiple myeloma]

PURPOSE

To assess the classification of Greipp et al in a group of multiple myeloma (MM) patients, in an attempt to correlate the morphological patterns with the clinico-biological features of the disease.

MATERIAL AND METHODS

Bone marrow aspirates from 135 patients with multiple myeloma were examined by two different observers.

RESULTS

Full accordance existed in 122 cases (90%). The four morphological MM subgroup distribution was: mature, 38%; intermediate, 30%; immature, 18%, and plasmoblastic, 14%. The analysis of the M component types with regard to morphology showed increased IgA cases within the intermediate (40%) and immature (48%) MM (p = 0.01), and Bence-Jones cases within the plasmoblastic MM (32%). On the contrary, no differences were found with regard to the clinical stage, although none of the plasmoblastic MM was in stage I. The incidence of renal insufficiency and of high bone-marrow infiltration progressively increased from mature to plasmoblastic MM, the difference between the extreme morphological groups being significant. The incidence of hypercalcaemia and lower paraprotein rates was higher in plasmoblastic myeloma, with significant difference with respect to mature myeloma (p = 0.05). The median survival was longer in intermediate (27.8 months) and mature (22.5 months) myelomas than in plasmoblastic (17.9 months) and immature (13.6 months) myelomas. After grouping the mature forms (intermediate plus mature) and the immature ones (plasmoblastic plus immature) the survival differences approached statistical significance (p = 0.07).

CONCLUSIONS

This study suggests that the morphological examination of plasma cells should be included in the prognostic criteria of multiple myeloma.

Development of acute leukaemia after idiopathic myelofibrosis

AIMS

To determine the characteristics of blastic transformation of idiopathic myelofibrosis.

METHODS

The clinical and haematological features, as well as the morphological characteristics of blast cells, were analysed in nine adults with blast transformation.

RESULTS

Most of the patients were male and had enlarged spleens and livers. Five of the patients had normal platelet counts, while all had pronounced anaemia and a moderate degree of leucocytosis. The duration of the acute phase was usually short: 16 (SD 8) weeks. Most myeloid cell lineages--granulocytic, monocytic, and megakaryocytic--were similarly distributed. One patient also had a hybrid (lymphoid-myeloid) phenotype. The morphological assessment of blast cells agreed with immunophenotyping in five out of the nine cases. The onset of the blastic phase was not related to previous treatment.

CONCLUSIONS

A pluripotential stem cell with preferential myeloid commitment would be the target cell of blast transformation in idiopathic myelofibrosis. Our immunophenotypic data do not support the concept of a preferential association between megakaryocytic lineage and the acute transformation of idiopathic myelofibrosis. The absence of previous treatment in some cases suggests that this kind of evolution is part of the natural history of idiopathic myelofibrosis.

Lymphoid subsets and prognostic factors in multiple myeloma. Cooperative Group for the Study of Monoclonal Gammopathies

In a uniform series of 170 untreated myeloma patients (MM) we investigated the distribution of T cell subsets in peripheral blood (PB) and their relationship with the most relevant disease characteristics, including survival. CD4 cells were significantly decreased both in percentage and absolute numbers (P less than 0.0001). On the other hand, the CD8 cells only showed a slight increase in relative numbers. Upon correlating the abnormalities in the distribution of T cells with other clinical and biological disease characteristics the most remarkable correlation was with survival. A low number of CD4 cells (less than 700 x 10(6)/l) was associated with both an advanced clinical stage and a shorter survival (20 v. 43 months, P = 0.01). Moreover, a significant correlation also exists between the decrease in CD4 cells and both high beta 2-microglobulin (beta 2M) levels and anaemia. On the other hand, no relationship was found with the type of M-component nor with the plasma cell phenotype. Finally multivariate analysis showed that the number of CD4 cells add independent prognostic information to other well-established tests for the assessment of disease outcome in patients with multiple myeloma.

Immunophenotypic, genomic and clinical characteristics of blast crisis of chronic myelogenous leukaemia

We have studied phenotypic and clinical features in a consecutive series of 45 patients with chronic myelogenous leukaemia (CML) in blast crisis (BC). In addition, in 22 of these patients we have analysed the genotypic characteristics including immunoglobulin, T-cell receptor (TCR) and major breakpoint cluster region (M-bcr) gene organization. The granulomonocytic and megakaryoblastic lineages are the most commonly involved in these BC of CML (33% and 33% of cases, respectively); only 18% of our cases displayed a lymphoid phenotype. Moreover, both morphological and immunophenotypic studies revealed the frequent coexistence of two or three cell populations, especially when the megakaryoblast component is involved. The lymphoid BC displayed the highest incidence of complete remissions although this was not associated with a longer survival. Only minor differences between the different myeloid subgroups were observed. Immunoglobulin heavy chain (IgH) gene rearrangement was found in five of the six lymphoid BC and in one myeloid BC. Only one case showed k light chain gene rearrangement. In all but one myeloid BC the TCR-beta gene was in germline configuration. The TCR-gamma gene was rearranged in all lymphoid and one myeloid BC, while TCR-delta gene rearrangement was detected in 67% and 16% of the lymphoid and myeloid BC, respectively. Most of the lymphoid BC (4/5) had the M-bcr breakpoint in subregion 3, while the myeloid BC had the breakpoint either in subregion 2 or 3. No differences between the different myeloid phenotypic subgroups were observed in relation to breakpoint.

[Diagnosis of the health of a diabetic population in the county of Priorato in Tarragona province]

A health diagnosis made over a two-year period in the basic health area of Falset is described (17 municipalities with populations between 39 and 2,603 inhabitants, making-up a total reference population of 7,283 habitants) in relation to the diabetic population of the Priorato county in Catalunya. This county is geographically heterogeneous, with semi-arid hilly landscape, with poor communications, a farming population and a notoriously hostile climate. The population pyramid, inclined towards progressive aging of the population, is evidence of a major migration from the country. By means of continuous education of health personnel, updating of information sources, improvement of registration systems, and final evaluation, the outlines of an action plan is worked out with a view to the organisation of diabetic care in this rural context. A total of 226 diabetics were counted: 15 type 1 (6.2%), and 211 type II (93.8%). The incidence of diagnosed diabetes in the basic health area is 3.1% (1.4% to 10.33%). The average age of the patients was 65.6 years with a preponderance of women (146 = 64.6%). In 92 patients (40.2%) the evolution time was less than 5 years. The insulinisation rate was calculated at 26.1%. The typical diabetic patient is a retired person or a housewife (87.8), with primary of elementary education (82.7%), supported by the family.

[Clinico-hematological characteristics of acute transformation of chronic myeloproliferative syndromes]

BACKGROUND

The aim of the present study was to analyze the blastic transformation occurring during chronic myeloproliferative diseases (CMPD) and to establish the differences between them.

METHODS

The clinical and hematological characteristics of 54 patients in blastic crisis (BC) of a CMPD were analyzed: 40 chronic myelogenous leukemias (CML), 9 idiopathic myelofibroses (IMF), 4 polycythemia vera (PV), and one essential thrombocythemia (ET). The results were analyzed by the BMDP statistical program.

RESULTS

The BC of CML appeared in younger patients (p less than 0.05). Only in this group did some patients achieve complete remission. Moreover, in this BC a greater incidence of visceromegalies and leukocytoses were observed. The BC of the IMF patients led to marked anemia (p less than 0.01) and bone marrow infiltration (p less than 0.05); these leukemias were more frequent in males and began with lymphadenopathies and visceromegalies. The transformations of PV were preceded by a longer chronic phase and had a lower incidence of visceromegalies and a nearly normal hemoglobin count value. The patient with acute leukemia secondary to ET did not display visceromegalies but did have anemia, leukopenia and a normal platelet count. None of the four groups responded to therapy, and their survival was short.

CONCLUSIONS

Blast transformations of different myeloproliferative disorders have their own idiosynchratic clinical and hematological characteristics, some of these may be related to the chronic phase of disease.

Acute leukemia after a primary myelodysplastic syndrome: immunophenotypic, genotypic, and clinical characteristics

We studied the nature of blast cells in 41 patients with acute leukemia following a previous primary myelodysplastic syndrome (MDS) by a combined multiparameter analysis including morphologic, immunophenotypic, and molecular genetic (Igs, T-cell receptor (TCR)-beta, -gamma, and -delta and the major breakpoint cluster region [M-bcr]) investigations. In addition, the clinical and hematologic characteristics according to the immunophenotype of blast cells were analyzed. Our results show that, although the granulocytic and/or monocytic lineages are those most commonly involved in these acute leukemias, other cell components, including the megakaryocytic and lymphoid, may be present (12% and 15% of the cases, respectively). Moreover, both morphologic and phenotypic studies show the frequent coexistence of two or three cell populations. Interestingly, in all cases the lymphoblastic component constantly displayed an early B phenotype (CD19+, CD10-, TdT+). Upon analyzing whether the type of MDS conditioned any differences in the immunophenotype of blast cells, we observed that, although the lymphoid lineage may be involved in all MDS subgroups, some differences emerge within the myeloid leukemic transformations. Thus, the refractory anemias with excess of blasts (RAEB) and RAEB in transformation displayed a significantly higher incidence of myeloblastic and megakaryoblastic transformations, while in the RA, RA with ring sideroblasts and chronic myelomonocytic leukemia, the granulo-monocytic phenotype predominated. In addition, our results show that the clinical and hematologic characteristics of these patients may be partially related to the immunophenotype of the blast cells. Ig heavy chain gene rearrangements were found in two of 19 patients analyzed (11%), one with a hybrid leukemia (lymphoid-myeloid) and the other with a granulo-monocytic phenotype. Two other hybrid transformations analyzed were in germline configuration. Gamma and delta gene rearrangements were found in 21% and 37% of these acute transformation, respectively. The TCR-beta and M-bcr were in germline configuration in all 19 cases studied. In summary, immunophenotype and molecular studies point to a pluripotent stem cell with preferential myeloid commitment as the target cell of leukemias following a primary MDS.

[Campylobacter jejuni infection in children of a rural community]

Colonization of the intestine with Campylobacter jejuni was followed longitudinally from birth in a cohort of 75 rural children with fecal cultures taken every fortnight and every time they had diarrhea. Only 25% of children initially colonized with C. jejuni during the first year of life, and 12% of children initially colonized during the second had diarrhea. The age at which a child was initially infected with C. jejuni was not a risk factor in relation with presence of disease. A higher illness-to-infection ratio (P less than 0.05) was found during subsequent colonization with C. jejuni when initial infection was associated with diarrhea. Risk of diarrhea during initial or subsequent colonization with C. jejuni was not related with the production of cholera-like enterotoxin, a cytotoxic active on HeLa cells or with adhesive ability to HEp-2 cells by the infecting strains.

[Hemangiopericytoma of the maxillary sinus: apropos of a case]

Haemangiopericytoma is a rare vascular tumour arising from the proliferation of pericytes which are cells surrounding the capillaries. Since 1949 only 54 cases of haemangiopericytomas of the nose and paranasal sinuses have been reported in the literature. Of the latter, only 8 cases originated from the maxillary sinus. We report a further case originated from the maxillary sinus.

[Chemodectomas of the carotid body. Apropos 2 cases]

The chemodectoma a paragangliomas of the carotid body are infrequent tumors in the daily medical practice, but they must be taken into account in the differential diagnosis of any lateral neck mass. We present two new cases, reconsidering the existing literature.

[Acute myocardial infarction in young adults. Analysis of risk factors and coronary angiography]

Eighty patients aged under forty, survivors of an episode of acute myocardial infarction (AMI), were studied by means of angiography. Thirty five had anterior wall infarction, 26 diaphragmatic wall, 9 lateral side and 10 non Q AMI. Tobacco addiction (92% vs 71.9%) and hyperlipemia (34% vs 18.8% were higher (p less than 0.01) that in the total AMI population. They presented an average ejection fraction of 0.56 +/- 0.15 and only in three patients was under 0.30. One, 2 and 3 vessels disease respectively of 43%, 22% and 16%, similar to another series published. A 19% of patients with normal angiography coronaries was seen significantly higher (p less than 0.01) than the observed in AMI in older patients. In conclusion in spite of the good prognosis of this group of patients, is necessary to insist in primary preventive campaigns, mainly against tobacco addiction and hyperlipemia, in order to reduce the frequency of AMI in young people.

Immunophenotypic heterogeneity of multiple myeloma: influence on the biology and clinical course of the disease. Castellano-Leones (Spain) Cooperative Group for the Study of Monoclonal Gammopathies

In 112 untreated myeloma patients we have analysed the immunophenotype of plasma cells both by immunofluorescence (IF) and immunocytochemistry (APAAP). Both techniques yielded similar results pointing to an important degree of heterogeneity in antigenic expression not only between different patients but also within the same patient. The expression of CD38 and Han-PC1 antigens (Ags) was almost constant (greater than 90% positive cases), while CD9 was detected in 66% of the cases. On the other hand, less than one third of patients were positive for CD10, CD20 and HLA-DR and generally with a weak expression (less than 30% positive plasma cells). In occasional cases plasma cells were weakly positive for the myelomonocytic markers CD13 (9%), CD15 (25%) and CD14 (6%). The possibility that this heterogeneity might be the result of different stages of differentiation of the neoplastic clone is suggested both by the positive correlation in the expression of some of these antigens (CD10, CD9, CD20, HLA-DR) and by the relationship between CD10 and myeloid antigens with immature plasma cell morphology. Finally, the cALLA antigen does not seem to be of significant value in predicting survival. Moreover, none of the other markers explored showed a clear influence in the course of the disease, although the tendency towards a lower survival found for the CD20+ cases as well as the association of the expression of some antigens and advanced clinical stage, may warrant further studies in a larger series of patients.

[Non-traumatic rupture of the spleen in malignant hemopathies. 2 new cases]

Spontaneous splenic rupture is an unusual complication of hematologic malignancies with a high mortality rate. We report two cases of non-traumatic splenic rupture: the first one was a patient with myelomonocytic leukaemia and the second one a previously undiagnosed patient with non Hodgkin's lymphoma, both of them survived after splenectomy. Emphasis on the necessity of an early diagnosis and treatment are made.

Evaluation of antibodies to hepatitis C virus in a study of transfusion-associated hepatitis

BACKGROUND

The hepatitis C virus (HCV) is now known to be the chief cause of transfusion-associated non-A, non-B hepatitis, but the prevalence of HCV among blood donors and the frequency of transmission by blood transfusion are unknown.

METHODS

To assess the sensitivity and specificity of a test for antibody to HCV, we tested serum samples from participants in a large study of transfusion-associated hepatitis. Samples were obtained prospectively from consecutive adults undergoing open-heart surgery in Spain, but were tested retrospectively, after the antibody enzyme immunoassay for anti-HCV became available.

RESULTS

Of 280 transfusion recipients given a total of 1109 units of blood, 27 (9.6 percent) had transfusion-associated non-A, non-B hepatitis (mean follow-up, 52 weeks) and 24 of the 27 seroconverted to anti-HCV-positive, whereas only 2 (0.8 percent) of the remaining transfusion recipients seroconverted. Among the 1044 donor specimens available for testing, 16 (1.5 percent) had anti-HCV antibody. Only 1 additional seropositive donor was found when 44 implicated donors who had been seronegative were retested 9 to 12 months later. Of the 16 recipients of anti-HCV-positive blood, 14 (88 percent) had transfusion-associated hepatitis and seroconverted to anti-HCV-positive. The remaining two recipients had neither hepatitis nor anti-HCV antibody. Among 25 patients with non-A, non-B hepatitis for whom all transfused blood was tested, 14 had received blood positive for anti-HCV.

CONCLUSIONS

About 90 percent of blood donors with antibody to HCV have infectious virus in their blood. The screening of blood donors for anti-HCV antibody should prevent about half the cases of transfusion-associated hepatitis, but the donors with infectious virus who are anti-HCV-negative may remain seronegative for prolonged periods.

Risk of diarrhea during the first year of life associated with initial and subsequent colonization by specific enteropathogens

The incidence of colonization by enteropathogenic, enterotoxigenic, enteroinvasive, and enterohemorrhagic Escherichia coli (detected by DNA hybridization with specific radiolabeled probes), Salmonella sp., Shigella sp., Campylobacter jejuni, and rotavirus was related to the presence of diarrhea in a cohort of 75 rural infants followed longitudinally during the first year of life. The study was carried out between August 1985 and February 1987 in the village of Lugar Sobre la Tierra Blanca, in the state of Morelos, 180 km southwest of Mexico City. Intestinal colonization by specific enteropathogens was followed with fecal cultures taken every fortnight and every time a child had diarrhea. Pathogens isolated from cultures taken in the 48 hours prior to the initiation of the diarrheal episode were considered to be associated with the disease. Diarrhea was detected in 82% of the children with initial isolation of enterohemorrhagic E. coli and in 64% of the children with enteropathogenic E. coli or Shigella sp. The risk of diarrhea associated with the initial isolation of other pathogens was lower, at 41% for rotavirus and approximately 25% for enterotoxigenic E. coli, Salmonella sp., and C. jejuni. Initial colonization by the enteropathogens studied, whether or not they were associated with diarrhea, prevented disease, but not colonization by the same organism, when the children were reinfected during the first year of life. Enteropathogenic E. coli adherence factor, human or porcine heat-stable enterotoxins, fimbrial colonization factor antigens, and Shiga-like toxins I and II were important pathogenic characteristics related to the presence of diarrhea and to protection against subsequent infection by the same organisms.

Hepatitis C virus antibodies among risk groups in Spain

The frequency of hepatitis C virus (HCV) infection in Spain was assessed by means of a recombinant-based immunoassay for serum anti-HCV antibodies. 836 serum samples were tested from 676 patients selected according to their risk of blood-borne viral infections and presence of liver disease. Among patients at high risk of infection (with or without liver disease) anti-HCV antibodies were found in 85% of prospectively followed patients with post-transfusion non-A, non-B hepatitis, 62% of patients with chronic hepatitis or cirrhosis and a history of blood transfusion, 70% of haemophiliacs receiving replacement therapy, 70% of intravenous drug abusers, and 20% of haemodialysis patients. Only 8% of homosexual men infected with human immunodeficiency virus and 6% of female contacts of drug abusers were positive. Among patients with liver disease and no history of parenteral exposure to blood, anti-HCV antibodies were detected in 38% with cryptogenic, alcoholic, or primary biliary cirrhosis and in 44% with chronic active hepatitis. Among healthy subjects without risk factors for hepatitis the overall prevalence of anti-HCV was 1.2%.

[Coronary dissection following coronary radiography]

We present 4 cases of dissection of the coronary arteries during coronary radiography, which required emergency surgery. The right coronary was dissected in 2 cases and the left coronary in the remaining cases. Coronary artery bypass was carried out using saphenous vein. Although one patient suffered myocardial infarction, all patients had successful recovery and evolution.