Providers' perspectives on the reproductive decision-making of BRCA-positive women

BACKGROUND

Reproductive decision-making is difficult for BRCA-positive women. Our objective was to assess the complexities of decision-making and identify decisional supports for patients and providers when discussing reproductive options prior to risk-reducing salpingo-oophorectomy (RRSO).

METHODS

This study was of qualitive design, using data collection via semi-structured interviews conducted from November 2018 to October 2020. Individuals were included if they were identified to provide care to BRCA-positive women. In total, 19 providers were approached and 15 consented to participate. Providers were recruited from three clinics in Toronto, Ontario located at academic centers: [1] A familial ovarian cancer clinic, [2] A familial breast cancer clinic and [3] A fertility clinic, all of which treat carriers of the BRCA1/BRCA2 genetic mutation. The interview guide was developed according to the Ottawa Decision Support Framework and included questions regarding reproductive options available to patients, factors that impact the decision-making process and the role of decisional support. Interviews were transcribed and transcripts were analyzed thematically using NVIVO 12.

RESULTS

Providers identified three major decisions that reproductive-aged women face when a BRCA mutation is discovered: [1] "Do I want children?"; [2] "Do I want to take the chance of passing on this the mutation?"; and [3] "Do I want to carry a child?" Inherent decision challenges that are faced by both providers and patients included difficult decision type, competing options, scientifically uncertain outcomes, and challenging decision timing. Modifiable decisional needs included: inadequate knowledge, unrealistic expectations, unclear values and inadequate support or resources. Identified clinical gaps included counselling time constraints, lack of reliable sources of background information for patients or providers and need for time-sensitive, geographically accessible, and centralized care.

CONCLUSION

Our study identified a need for a patient information resource that can be immediately provided to patients who carry a BRCA genetic mutation. Other suggestions for clinical practice include more time during consultation appointments, adequate follow-up, value-centric counseling, access to psychosocial support, and a specialized decisional coach.

Optical coherence tomography versus angiography and intravascular ultrasound to guide coronary stent implantation: A systematic review and meta-analysis

BACKGROUND

Optical coherence tomography (OCT) is an adjunct to angiography-guided coronary stent placement. However, in the absence of dedicated, appropriately powered randomized controlled trials, the impact of OCT on clinical outcomes is unclear.

OBJECTIVE

To conduct a systematic review and meta-analysis of all available studies comparing OCT-guided versus angiography-guided and intravascular ultrasound (IVUS)-guided coronary stent implantation.

METHODS

MEDLINE and Cochrane Central were queried from their inception through July 2022 for all studies that sought to compare OCT-guided percutaneous coronary intervention (PCI) to angiography-guided and IVUS-guided PCI. The primary endpoint was minimal stent area (MSA) compared between modalities. Clinical endpoints of interest were all-cause and cardiovascular mortality, major adverse cardiovascular events (MACE), myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), and stent thrombosis (ST). Risk ratios (RRs) and mean differences (MDs) with their corresponding 95% confidence intervals (CIs) were pooled using a random-effects model.

RESULTS

Thirteen studies (8 randomized control trials and 5 observational studies) enrolling 6312 participants were included. OCT was associated with a strong trend toward increased MSA compared to angiography (MD = 0.36, p = 0.06). OCT-guided PCI was also associated with a reduction in the incidence of all-cause mortality [RR = 0.59, 95% CI (0.35, 0.97), p = 0.04] and cardiovascular mortality [RR = 0.41, 95% CI (0.21, 0.80), p = 0.009] compared with angiography-guided PCI. Point estimates favored OCT relative to angiography in MACE [RR = 0.75, 95% CI (0.47, 1.20), p = 0.22] and MI [RR = 0.75, 95% CI (0.53, 1.07), p = 0.12]. No differences were detected in ST [RR = 0.71, 95% CI (0.21, 2.44), p = 0.58], TLR [RR = 0.71, 95% CI (0.17, 3.05), p = 0.65], or TVR rates [RR = 0.89, 95% CI (0.46, 1.73), p = 0.73]. Compared with IVUS guidance, OCT guidance was associated with a nonsignificant reduction in the MSA (MD = -0.16, p = 0.27). The rates of all-cause and cardiovascular mortality, MACE, MI, TLR, TVR, or ST were similar between OCT-guided and IVUS-guided PCI.

CONCLUSIONS

OCT-guided PCI was associated with reduced all-cause and cardiovascular mortality compared to angiography-guided PCI. These results should be considered hypothesis generating as the mechanisms for the improved outcomes were unclear as no differences were detected in the rates of TLR, TVR, or ST. OCT- and IVUS-guided PCI resulted in similar post-PCI outcomes.

Synchronous timing of abrupt climate changes during the last glacial period

Abrupt climate changes during the last glacial period have been detected in a global array of palaeoclimate records, but our understanding of their absolute timing and regional synchrony is incomplete. Our compilation of 63 published, independently dated speleothem records shows that abrupt warmings in Greenland were associated with synchronous climate changes across the Asian Monsoon, South American Monsoon, and European-Mediterranean regions that occurred within decades. Together with the demonstration of bipolar synchrony in atmospheric response, this provides independent evidence of synchronous high-latitude-to-tropical coupling of climate changes during these abrupt warmings. Our results provide a globally coherent framework with which to validate model simulations of abrupt climate change and to constrain ice-core chronologies.

Primordial germ cells do not migrate along nerve fibres in marmoset monkey and mouse embryos

Primordial germ cells (PGCs) are the embryonic precursors of spermatozoa and eggs. In mammals, PGCs arise early in embryonic development and migrate from their tissue of specification over a significant distance to reach their destinations, the genital ridges. However, the exact mechanism of translocation is still debated. A study on human embryos demonstrated a very close spatial association between migrating PGCs and developing peripheral nerves. Thus, it was proposed that peripheral nerves act as guiding structures for migrating PGCs. The goal of the present study is to test whether the association between nerves and PGCs may be a human-specific finding or whether this represents a general strategy to guide PGCs in mammals. Therefore, we investigated embryos of different developmental stages from the mouse and a non-human primate, the marmoset monkey (Callithrix jacchus), covering the phase from PGC emergence to their arrival in the gonadal ridge. Embryo sections were immunohistochemically co-stained for tubulin beta-3 chain (TUBB3) to visualise neurons and Octamer-binding protein 4 (OCT4 (POU5F1)) as marker for PGCs. The distance between PGCs and the nearest detectable neuron was measured. We discovered that in all embryos analysed of both species, the majority of PGCs (>94%) was found at a minimum distance of 50 µm to the closest neuron and, more importantly, that the PGCs had reached the gonads before any TUBB3 signal could be detected in the vicinity of the gonads. In conclusion, our data indicate that PGC migration along peripheral nerves is not a general mechanism in mammals.

Persistent influence of obliquity on ice age terminations since the Middle Pleistocene transition

Radiometric dating of glacial terminations over the past 640,000 years suggests pacing by Earth's climatic precession, with each glacial-interglacial period spanning four or five cycles of ~20,000 years. However, the lack of firm age estimates for older Pleistocene terminations confounds attempts to test the persistence of precession forcing. We combine an Italian speleothem record anchored by a uranium-lead chronology with North Atlantic ocean data to show that the first two deglaciations of the so-called 100,000-year world are separated by two obliquity cycles, with each termination starting at the same high phase of obliquity, but at opposing phases of precession. An assessment of 11 radiometrically dated terminations spanning the past million years suggests that obliquity exerted a persistent influence on not only their initiation but also their duration.

Organic Compounds in a Sub-Antarctic Ice Core: A Potential Suite of Sea Ice Markers

Investigation of organic compounds in ice cores can potentially unlock a wealth of new information in these climate archives. We present results from the first ever ice core drilled on sub-Antarctic island Bouvet, representing a climatologically important but understudied region. We analyze a suite of novel and more familiar organic compounds in the ice core, alongside commonly measured ions. Methanesulfonic acid shows a significant, positive correlation to winter sea ice concentration, as does a fatty acid compound, oleic acid. Both may be sourced from spring phytoplankton blooms, which are larger following greater sea ice extent in the preceding winter. Oxalate, formate, and acetate are positively correlated to sea ice concentration in summer, but sources of these require further investigation. This study demonstrates the potential application of organic compounds from the marine biosphere in generating multiproxy sea ice records, which is critical in improving our understanding of past sea ice changes.

Feasibility of a new arthroscopic shelf acetabuloplasty technique for hip instability related to moderate dysplasia

Dysplasia-related hip instability causes pain and intra-articular derangement. The bone, the joint capsule, and the labrum are involved. We describe a surgical procedure of limited invasiveness that corrects the dysplasia by creating an acetabular shelf, repairs the secondary lesions by suturing the labrum and tightening the capsule, and corrects cam femoro-acetabular impingement if present.

Direct Injection Liquid Chromatography High-Resolution Mass Spectrometry for Determination of Primary and Secondary Terrestrial and Marine Biomarkers in Ice Cores

Many atmospheric organic compounds are long-lived enough to be transported from their sources to polar regions and high mountain environments where they can be trapped in ice archives. While inorganic components in ice archives have been studied extensively to identify past climate changes, organic compounds have rarely been used to assess paleo-environmental changes, mainly due to the lack of suitable analytical methods. This study presents a new method of direct injection high performance liquid chromatography-mass spectrometry (HPLC-MS) analysis, without the need of preconcentrating the melted ice, for the determination of a series of novel biomarkers in ice core samples indicative of primary and secondary terrestrial and marine organic aerosol sources. Eliminating a preconcentration step reduces contamination potential and decreases the required sample volume thus allowing a higher time resolution in the archives. The method is characterized by limits of detection (LODs) in the range of 0.01–15 ppb, depending on the analyte, and accuracy evaluated through an interlaboratory comparison. We find that many components in secondary organic aerosols (SOAs) are clearly detectable at concentrations comparable to those previously observed in replicate preconcentrated ice samples from the Belukha glacier, Russian Altai Mountains. Some compounds with low recoveries in the preconcentration steps are now detectable in samples with this new direct injection method significantly increasing the range of environmental processes and sources that become accessible for paleo-climate studies.

A new method for the determination of primary and secondary terrestrial and marine biomarkers in ice cores using liquid chromatography high-resolution mass spectrometry

The majority of atmospheric compounds measured in ice cores are inorganic, while analysis of their organic counterparts is a less well developed field. In recent years, understanding of formation, transport pathways and preservation of these compounds in ice and snow has improved, showing great potential for their use as biomarkers in ice cores. This study presents an optimised analytical technique for quantification of terrestrial and marine biosphere emissions of secondary organic aerosol (SOA) components and fatty acids in ice using HPLC-MS analysis. Concentrations of organic compounds in snow and ice are extremely low (typically ppb or ppt levels) and thus pre-concentration is required prior to analysis. Stir bar sorptive extraction (SBSE) showed potential for fatty acid compounds, but failed to recover SOA compounds. Solid phase extraction (SPE) recovered compounds across both organic groups but methods improving some recoveries came at the expense of others, and background contamination of fatty acids was high. Rotary evaporation was by far the best performing method across both SOA and fatty acid compounds, with average recoveries of 80%. The optimised preconcentration - HPLC-MS method achieved repeatability of 9% averaged for all compounds. In environmental samples, both concentrations and seasonal trends were observed to be reproducible when analysed in two different laboratories using the same method.

Bisphenol A affects larval growth and advances the onset of metamorphosis in Drosophila melanogaster

Exposure to Bisphenol A (BPA) has been reported to dysregulate endocrine pathways in a wide array of vertebrate species. The effects of BPA on invertebrate species are less well understood. We tested the effects of BPA on growth and development in Drosophila as these processes are governed by well-studied endocrine pathways. In this study, we tested the effects of three concentrations of BPA (0.1mg/L, 1mg/L or 10mg/L) and found a statistically significant increase in larval growth for the low dose treatment group (0.1mg/L), but not statistically significant for the high dose treatment group (10mg/L). BPA exposure resulted in an increased body size in treated animals at 48, 72 and 96h after egg laying (AEL). This finding reflects a non-monotonic dose-response that has been observed for an increasing number of endocrine disrupting compounds. The increase in growth rate found for all treatment groups was associated with a statistically significant increase in food intake observed at 72h AEL. Furthermore, we observed that the increased growth rate was coupled with an earlier onset of pupariation consistent with previously reported phenotypes resulting from increased activity of insulin/insulin growth factor signaling (IIS) in Drosophila. Since the timing of the onset of pupariation in Drosophila is controlled through the complex interaction of the IIS and the ecdysone signaling pathways, our findings suggest that BPA exerts its effects through disruption of endocrine signaling in Drosophila.

Impact of chronic atrial fibrillation in patients with severe heart failure and indication for CRT: data of two registries with 711 patients (1999-2006 and 2007-6/2008)

AIMS

Atrial fibrillation (AF) is a relevant comorbidity in heart failure (HF) patients. In milestone cardiac resynchronization therapy (CRT) studies, patients with AF were excluded. We sought to investigate the influence of chronic atrial fibrillation (AF) on patients with CRT. AV node (AVN) ablation is frequently recommended. Converting AF to sinus rhythm (SR) is not a standard concept.

METHODS

A total of 584 consecutive patients with CRT devices were included in a single-center registry from 1999-2006 (retrospective registry) and 127/324 patients from 2007-06/2008 (prospective registry). The impact of persistent AF (group 1) on clinical and echocardiographic improvement compared with patients in SR (group 2) after 12 (6) months follow-up were analyzed. Re-establishing SR after initial cardioversion or need for AVN ablation was examined.

RESULTS

In the retrospective registry, 139 (24%) patients presented with AF (group 1) and 445 with SR (group 2). The groups differed in age, gender, and left atrium (LA) size but not in NYHA class, ejection fraction (EF), left ventricular end-diastolic dimension (LVEDD), B-type natriuretic peptide (BNP) levels, QRS width, and underlying disease. After 1 year, CRT improvement of NYHA class and EF was similar with higher mortality in group 1 (12% vs. 7%; OR 1.80; 95% confidence interval 0.95-3.4). The AF group presented with SR in 33/82 (40%) patients and 11% needed AVN ablation. The prospective data showed 27 (21%) patients in AF with conversion to SR in 41% after 6 months.

CONCLUSION

Patients with severe HF and chronic AF had a comparable improvement with CRT as those in SR. CRT is a successful treatment option in patients with chronic AF offering the potential to restore SR in a significant number of patients.

800,000 years of abrupt climate variability

We constructed an 800,000-year synthetic record of Greenland climate variability based on the thermal bipolar seesaw model. Our Greenland analog reproduces much of the variability seen in the Greenland ice cores over the past 100,000 years. The synthetic record shows strong similarity with the absolutely dated speleothem record from China, allowing us to place ice core records within an absolute timeframe for the past 400,000 years. Hence, it provides both a stratigraphic reference and a conceptual basis for assessing the long-term evolution of millennial-scale variability and its potential role in climate change at longer time scales. Indeed, we provide evidence for a ubiquitous association between bipolar seesaw oscillations and glacial terminations throughout the Middle to Late Pleistocene.

800,000 years of abrupt climate variability

We constructed an 800,000-year synthetic record of Greenland climate variability based on the thermal bipolar seesaw model. Our Greenland analog reproduces much of the variability seen in the Greenland ice cores over the past 100,000 years. The synthetic record shows strong similarity with the absolutely dated speleothem record from China, allowing us to place ice core records within an absolute timeframe for the past 400,000 years. Hence, it provides both a stratigraphic reference and a conceptual basis for assessing the long-term evolution of millennial-scale variability and its potential role in climate change at longer time scales. Indeed, we provide evidence for a ubiquitous association between bipolar seesaw oscillations and glacial terminations throughout the Middle to Late Pleistocene.

Methane and nitrous oxide in the ice core record

Polar ice cores contain, in trapped air bubbles, an archive of the concentrations of stable atmospheric gases. Of the major non-CO2 greenhouse gases, methane is measured quite routinely, while nitrous oxide is more challenging, with some artefacts occurring in the ice and so far limited interpretation. In the recent past, the ice cores provide the only direct measure of the changes that have occurred during the industrial period; they show that the current concentration of methane in the atmosphere is far outside the range experienced in the last 650,000 years; nitrous oxide is also elevated above its natural levels. There is controversy about whether changes in the pre-industrial Holocene are natural or anthropogenic in origin. Changes in wetland emissions are generally cited as the main cause of the large glacial-interglacial change in methane. However, changing sinks must also be considered, and the impact of possible newly described sources evaluated. Recent isotopic data appear to finally rule out any major impact of clathrate releases on methane at these time-scales. Any explanation must take into account that, at the rapid Dansgaard-Oeschger warmings of the last glacial period, methane rose by around half its glacial-interglacial range in only a few decades. The recent EPICA Dome C (Antarctica) record shows that methane tracked climate over the last 650,000 years, with lower methane concentrations in glacials than interglacials, and lower concentrations in cooler interglacials than in warmer ones. Nitrous oxide also shows Dansgaard-Oeschger and glacial-interglacial periodicity, but the pattern is less clear.

A new approach to overcome natural cholesterol interference during simultaneous determination of two stable isotope-enriched cholesterol tracers in human plasma

We have developed a validated gas chromatography/mass spectrometry (GC/MS) method with two labelled cholesterol tracers, i.e. (2)H(4) ([2H4]-Chol) and (2)H(7) ([2H7]-Chol) enriched moieties, with a new way of calculating the abundance of labelled cholesterol in plasma without natural cholesterol interference. The isotopomers of the analytes could interfere during analysis. Elimination of these interferences can be performed by the blank or mathematical subtraction method. Validation was performed with the two interference elimination methods. For both methods, linearity was obtained in the range 5 x 10(-4) to 10(-2) mM for both labelled cholesterol moieties. In the same range, repeatability and reproducibility were less than 6.5% and 7.5% for [2H4]-Chol and [2H7]-Chol, respectively. Accuracy was about 100% and recoveries always included 100% for the two labelled cholesterols. We demonstrate that measurement of blank plasma is not necessary when using the validated abundance isotope calculation method. This saves time, reagent and samples. This calculation strategy can be extrapolated to comparable tracer approaches.

Pediatric renal transplantation: a single center experience over 14 years

Between 1989 and 2003, 100 transplants were performed in 96 patients at the pediatric nephrology unit of the Calvo Mackenna Children's Hospital. Mean age 10.9 +/- 3.9 yr (1-17.6), 30% from LD. Donors were younger than 5 yr in five patients and all recipients received an 'en bloc' graft. Original disease was hypo/dysplasia 27%, reflux nephropathy 22 and 17% chronic glomerulonephritis. The immunosuppressive protocol during the first period (n = 56, 1989-2000): Cyclosporine, steroids and azathioprine, and during the second period (n = 44, 2001-2003): FK, steroids, MMF and anti-CD25 antibody (mAbs). AR was reported in 22 patients, 11% in LD, 31% in DD (p < 0.01). The AR rate decreased from 40 to 8% after anti-CD25 monoclonal induction. Patient actuarial survival rate at 1, 3 and 5 yr was 100% for LD and 96% for DD. The overall actuarial graft survival at 1,3, and 5 yr was 96.7, 96.7 and 71% for LD and 89, 76 and 73% for DD donors. Graft survival rate improved from the first period (1989-2000) to the second period (2001-2003; p = 0.05). No difference in graft survival rate with HLA-A,B,DR matching was found. Graft survival rate was better when cold ischemia time was <24 h (p < 0.01). CMV infections increased from 19 to 40% when MMF and anti-CD25 Ab were introduced (p < 0.01). The height/age Z score at 1, 3 and 5 yr post-transplant was -2.2, -2.1, -2.2, respectively, for children older than 7 yr and -1.8, -1.9, -2.1 for those transplanted younger than 7 yr of age who were switched to alternate day steroids (p < 0.01). The cause of graft lost was: chronic rejection eight, non-adherence four, AR four and vascular thrombosis two. The cause of death in two patients was fungus septicemia and accelerated rejection. Pediatric renal transplantation can be performed in our group with acceptable morbidity, low mortality and graft survival rates similar to other reports in North America and Western Europe. Graft survival rate improved with newer immunosuppression and greater experience at the center. Management of non-adherence and chronic rejection remain the major challenges.

Bronchiectasis in children after renal or liver transplantation: a report of five cases

More effective immunosuppressive treatment in children following organ transplantation has significantly improved the survival of the grafts. Therefore, quality of life, long-term prognosis and adverse drug reactions have become more important. One of the main complications of immunosuppressive drugs is infections of the respiratory tract, but irreversible damage to the airways has not been described after renal or liver transplantation. Five children following transplantation of kidney or liver were referred to the Paediatric Pulmonology department because of chronic respiratory complaints. Pulmonary function tests and HRCT scan were performed as routine patient care. Four children with a renal transplant and one with a liver transplant showed chronic bronchitis and moderate to severe airways obstruction. HRCT showed bronchiectasis in all of them. We speculate that the immunosuppressive treatment (in)directly contributes to irreversible airway damage. We recommend including follow-up of lung function in the post-transplantation protocol and considering bronchiectasis in case of respiratory symptoms, to try preventing further damage to the lung.

Loss of 9p21 is embedded in a complex but consistent pattern of genomic imbalances in oral squamous cell carcinomas

35 oral squamous cell carcinomas examined previously by comparative genomic hybridization (CGH) exhibited 5 up to 47 copy number alterations (CNAs). 13 of those cases showed a loss of parts of the short arm of chromosome 9, band p21 being affected in all of these cases. A highly complex but strikingly consistent pattern of genomic imbalances with an average 31.5 CNAs per tumor was associated with this deletion, and gains clearly dominated over losses of genomic material. Comparable patterns, however, could also be found in tumors with a high number of CNAs (24 CNAs) but without the deletion. Low numbers of imbalances were accompanied by low consistency of the CNA patterns. None of these latter cases showed the deletion 9p21. 66.7% of the dim(9p21)-positive tumors were of class pT4 (vs. 22% in dim(9p21)-negative cases), 77% of stage III or IV (vs. 47% in the group without the deletion), but only 8% of the dim(9p21)-positive tumors were classified as grade 3 (vs. 41% in the negative group). Other clinicopathologic features like prevalence of relapse, or survival time could not be as clearly associated with the deletion. For instance, short relapse-free survival was clearly associated with a high number of CNAs, rather independent of presence or absence of dim(9p21) in the affected tumor. From these findings it is concluded that previously found associations of 9p21 deletion with clinical parameters can reasonably be estimated only in the context of the pattern and complexity of the genomic imbalances accompanying this chromosomal loss in the examined tumors.

[Anti-semitism in medicine and Jewish emancipation - the quarrel between the Gottingen obstetrician Friedrich Benjamin Osiander and his Jewish former student Joseph Jacob Gumprecht (circa 1800)]

This article analyzes the behavior of the renowned professor of obstetrics Friedrich Osiander towards his Jewish former student, the private lecturer Joseph Jacob Gumprecht. In a public academic debate between the two of them, Osiander made use of anti-Semitic arguments. He did so even though his medical ideas and practice were based on concepts of Enlightenment and especially religious tolerance. An analysis of Osiander's behavior shows that his denunciations were hardly emotional outbursts against Gumprecht. Rather, they were sober pedagogic attempts to cleanse Gumprecht from what Osiander saw as his "Jewishness", thereby helping him on his climb into bourgeois academic society. This interpretation fits well with the German "etatistic" version of Jewish emancipation: Jews were able to gain equal standing, but only under the condition of moral "improvement", or ridding themselves of all "Jewish attitudes." Thus, "Enlightened" ideas of Jewish emancipation were partly based on beliefs in Jewish moral inferiority. It is significant that the example under investigation happened in a medical faculty, since this was a prime location for acculturated Jews to meet Gentile scholars who represented the Enlightenment-influenced ideas of the times.

Enalapril and prednisone in children with nephrotic-range proteinuria

The effect of enalapril and low prednisone doses on the urinary protein electrophoretic pattern was studied in 13 pediatric patients with glomerular diseases and steroid-resistant nephrotic syndrome. Enalapril was administered at doses of 0.2-0.6 mg/kg per day for 24-84 months, and prednisone was introduced 2 months later in 11 patients at doses of 30 mg/m2 on alternate days. The urine protein electrophoretic pattern showed a reduction of 80% and 70% in the total protein and albumin, respectively, after enalapril. Total urinary protein decreased from 5.46 to 1.1 g/m2 per day (P<0.001). A marked change from a pattern of non-selective urinary protein loss to an albumin-selective proteinuria was observed. Mean total plasma proteins increased from 4.7 to 5.43 g/dl (P<0.001). Four patients became free of proteinuria 24 months after enalapril was started, but only 2 remained free of proteinuria at 48 months of follow-up. The other 11 patients had persistent albuminuria of between 0.5 and 2.6 g/m2 per day with a selective urinary electrophoretic pattern. No additional decrease was observed after steroids were introduced. A clinical improvement in edema was observed in all children. Three patients developed transient acute renal failure, during the course of an infectious disease; 2 developed peritonitis and 1 pneumopathy. In these patients withdrawal of enalapril was necessary until a complete recovery of renal function was observed. Four patients were hypertensive on admission, achieving normal blood pressure 1 month after enalapril was started. No episodes of systemic arterial hypotension were seen. Creatinine clearance and serum potassium showed no statistically significant change.