Impact of the COVID-19 pandemic in childhood and adolescent cancer care in northern Tanzania: a cross-sectional study

INTRODUCTION

The SARS-CoV-2 (COVID-19) pandemic has strained healthcare systems and presented unique challenges for children requiring cancer care, particularly in low- and middle-income countries. This study aimed to assess the impact of the COVID-19 pandemic on access to cancer care for children and adolescents in Northern Tanzania.

METHODS

In this cross-sectional study, we assessed the demographic and clinical characteristics of 547 pediatric and adolescent cancer patients (ages 0-19 years old) between 2016 and 2022 using the population-based Kilimanjaro Cancer Registry (KCR). We categorized data into pre-COVID-19 (2016-2019) and COVID-19 (2020-2022) eras, and performed descriptive analyses of diagnostic, treatment, and demographic information. A secondary analysis was conducted on a subset of 167 patients with stage of diagnosis at presentation.

RESULTS

Overall admissions nearly doubled during the pandemic (n = 190 versus 357). The variety of diagnoses attended at KCMC increased during the pandemic, with only five groups of diseases reported in 2016 to twelve groups of diseases in 2021. Most patients were diagnosed at a late stage (stage III or IV) across eras, with the proportion of under-five years old patients increasing late-diagnoses from 29.4% (before the pandemic), 52.8% (during the pandemic), when compared to the overall cohort. Around 95% of children in this age category reported late-stage diagnosis during the pandemic. Six out of the twelve cancer site groups also reported an increase in late-stage diagnosis. During the pandemic, the proportion of children receiving surgery increased from 15.8 to 30.8% (p < 0.001).

CONCLUSION

Childhood and adolescent cancer care changed in Northern Tanzania during the COVID-19 pandemic, with increased late-stage diagnoses presentations among younger patients and the increased use of surgical therapies in the context of a growing practice. Understanding the impact of the COVID-19 pandemic on pediatric and adolescent cancer care can help us better adapt healthcare systems and interventions to the emerging needs of children and adolescents with cancer in the midst of a health crisis.

Modeling the global impact of reducing out-of-pocket costs for children's surgical care

Over 1.7 billion children lack access to surgical care, mostly in low- and middle-income countries (LMICs), with substantial risks of catastrophic health expenditures (CHE) and impoverishment. Increasing interest in reducing out-of-pocket (OOP) expenditures as a tool to reduce the rate of poverty is growing. However, the impact of reducing OOP expenditures on CHE remains poorly understood. The purpose of this study was to estimate the global impact of reducing OOP expenditures for pediatric surgical care on the risk of CHE within and between countries. Our goal was to estimate the impact of reducing OOP expenditures for surgical care in children for 149 countries by modeling the risk of CHE under various scale-up scenarios using publicly available World Bank data. Scenarios included reducing OOP expenditures from baseline levels to paying 70%, 50%, 30%, and 10% of OOP expenditures. We also compared the impact of these reductions across income quintiles (poorest, poor, middle, rich, richest) and differences by country income level (low-income, lower-middle-income, upper-middle-income, and high-income countries).Reducing OOP expenditures benefited people from all countries and income quintiles, although the benefits were not equal. The risk of CHE due to a surgical procedure for children was highest in low-income countries. An unexpected observation was that upper-middle income countries were at higher risk for CHE than LMICs. The most vulnerable regions were Africa and Latin America. Across all countries, the poorest quintile had the greatest risk for CHE. Increasing interest in financial protection programs to reduce OOP expenditures is growing in many areas of global health. Reducing OOP expenditures benefited people from all countries and income quintiles, although the benefits were not equal across countries, wealth groups, or even by wealth groups within countries. Understanding these complexities is critical to develop appropriate policies to minimize the risks of poverty.

Prevalence and outcomes of pediatric surgical conditions at Connaught Hospital in Freetown: a retrospective study

Background

Sub-Saharan Africa experiences a disproportionate amount of pediatric surgical disease, with 80% of children lacking access to timely, affordable, and safe surgical care. This study aims to characterize the burden of disease and outcomes of pediatric surgical conditions at Connaught Hospital, the main pediatric referral hospital in Sierra Leone.

Methods

This retrospective and hospital-based study included children up to 15 years old who were operated on between 2015 and June 2016 at Connaught Hospital in Freetown, Sierra Leone. Descriptive and inferential statistics were used to characterize the distribution of disease and compare all variables against age category and mortality.

Findings

A total of 215 patients were included in this study of which 72.5% (n=132) were male and 27.5% (n=50) were female. Most of the patients were diagnosed with congenital anomalies (60.9%; n=131). However, infection was the leading diagnosis (60.5%; n=23) among patients aged 5-10 years (n=38). Inguinal hernia was the leading condition (65.0%; n=85) among patients presenting with a congenital anomaly. The condition with the highest mortality was infections (17.0%; n=8), followed by other conditions (9.1%; n=2) and congenital anomalies (3.1%; n=4). Based on the results of this study, over 7000 children with inguinal hernias remain untreated annually in Freetown, Sierra Leone.

Conclusion

This study quantifies the burden of surgical disease among children, a foundational step toward the prioritization of pediatric surgical care in national health agendas, the development of evidence-based interventions, and the strategic allocation of resources in Sierra Leone.

[Prevalence, risk of progression and quality of life assessment in adolescents undergoing school screening for adolescent idopathic scoliosis]

OBJECTIVE

To determine the prevalence of adolescent idiopathic scoliosis (AIS), progression risk, and quality of life in students aged from 10 to 18 years.

PATIENTS AND METHOD

Cross-sectional descriptive study in students 10 - 18 years old from 5 communes in Santiago, Chile, between 2015-2016. Adam's Test was performed and the angle trunk rotation (ATR) at the thoracic, thoracolumbar, and lumbar levels were measured with a scoliometer. If ATR was ≥ 6°, anteroposterior and lateral radiological images of the spine were taken, and Cobb angle was measured. Scoliosis was confirmed if the Cobb angle was ≥ 10° plus vertebral rotation. Progression factor was calculated with Lonstein and Carlson formula. Quality of life was assessed through spinal deformities questionnaires and the trunk appearance perception scale.

RESULTS

1200 students were evaluated, 54.9% were female, and 8.17% had ATR ≥ 6°. We found mild scoliosis in 2.91%, moderate in 0.75% and severe in 0.17%. Total prevalence was 3.83% (CI 95%: 2.74 - 4.92). 82.61% of the cases had a late diagnosis, after their growth spurt. Of the patients with scoliosis, 21.74% had a progression risk ≥ 50%. Quality of life had a positive correlation with scoliosis severity, not statistically significant.

CONCLUSIONS

Prevalence of AIS was 3.83%. Most patients were diagnosed after their growth spurt with high progression risk. Quality of life showed a weak positive correlation with scoliosis severity.

Desafíos y aprendizajes para la promoción de la salud durante la pandemia de la COVID-19 en Chile. Un análisis de experiencias locales desde la salud colectiva

La Promoción de la Salud (PS) es una función esencial de la salud pública que se ha puesto en tensión frente a la pandemia de la COVID-19, dado que los discursos y estrategias basados en la prevención y curación de la enfermedad han invisibilizado las condiciones de vida e inequidad que son centrales para la PS. La salud colectiva latinoamericana plantea cuestionamientos prácticos y epistemológicos sobre las acciones ante la epidemia en los países del Sur Global, proponiendo enfoques alternativos al paradigma biomédico y a lo que este entiende como PS. Desde la salud colectiva, la PS tiene como elementos centrales la autonomía de las comunidades, la importancia de sus saberes, y el fomento de acciones colectivas territoriales. Este artículo, a través de una cronología crítica de la pandemia en dos territorios, describe situaciones documentadas que ponen en evidencia el despliegue de condiciones esenciales de posibilidad para una PS desde la salud colectiva, es decir, el papel de la justicia social en la organización comunitaria, la perspectiva territorial y los procesos emancipatorios y de construcción de autonomía. Los casos analizados corresponden a un territorio insular del sur de Chile y a una comuna urbana de la capital del país, elaborados mediante el involucramiento directo de los investigadores y una revisión documental y de prensa. Sus antecedentes y contextualización evidencian las modalidades concretas que toma la PS durante la pandemia en dos contextos con características diversas, permitiendo identificar desafíos y arribar a aprendizajes iniciales sobre el desarrollo de una PS territorialmente situada.

Preparation of human resources for future nuclear energy using FBNR as the instrument of learning

An increasing number of developing countries are showing interest to become the emerging countries to nuclear energy. Most of these countries lack human resources and adequate infrastructures to enter such a venture. The principle objective of activities of FBNR Group is to train human resources for the countries that at the present lack the necessary conditions, but aim at the future clean and safe nuclear energy through the fourth generation and INPRO compatible nuclear reactors. The preparation for the future nuclear energy is done through development of innovative nuclear reactor that meets the INPRO philosophies and criteria. These countries may or may not have decided as yet to utilize nuclear energy, but are interested to gain a strong educational foundation for their future. The research and development of a small innovative nuclear reactor FBNR is used as the instrument for learning. The young scientists will learn how to be innovative with the vision of INPRO philosophy and criteria.

Ontogenetic and spatiotemporal variability in anchoveta Engraulis ringens diet off Peru

In this study, historical data available since 1954 were used to get new insight to ontogenetic and spatiotemporal variability in Peruvian anchovy or anchoveta Engraulis ringens diet. Whatever the period, E. ringens foraged mainly on macrozooplankton and the importance of euphausiids in E. ringens diet appears directly related to euphausiids abundance. This bottom-up effect is also observed at smaller scale because the euphausiids fraction increased with E. ringens total length and euphausiids accessibility. Selecting the largest prey, the euphausiids, provides an energetic advantage for E. ringens in its ecosystem where oxygen depletion imposes strong metabolic constraints on pelagic fishes. This study illustrates the plasticity of E. ringens that allows it to cope with its highly variable environment.

In vitro antifungal activity of the diterpenoid 7 alpha-hydroxy-8(17)-labden-15-oic acid and its derivatives against Botrytis cinerea

We investigated the inhibitory effect of the natural diterpenoids, 7α-hydroxy-8(17)-labden-15-oic acid (salvic acid, 1), 7α-acetanoyloxy-8(17)-labden-15-oic acid (acetylsalvic acid, 2) and the hemisynthetic diterpenoids 7α-acyloxy-8(17)-labden-15-oic acids derivatives, 7α-propanoyloxy-8(17)-labden-15-oic acid (propanoylsalvic acid, 3), 7α-butanoyloxy-8(17)-labden-15-oic acid (butanoylsalvic acid, 4) and 7α-isopentanoyloxy-8(17)-labden-15-oic acid (isopentanoylsalvic acid, 5), against Botrytis cinerea. Diterpenoid fungitoxicity was assessed using the radial growth test method. All diterpenoids, with the exception of isopentenoylsalvic acid, inhibited the mycelial growth of B. cinerea in solid media. Shortest side-chain diterpenoids were more effective than the derivatives with longer chains in the inhibition of B. cinerea mycelial growth. The results suggest that hydrophobicity and structural features would be important factors in the antifungal effect of these diterpenoids. Studies on a possible action mechanism of natural diterpenoids, salvic acid and acetylsalvic acid, showed that these diterpenoids exerted their effect by a different mechanism. Salvic acid did not alter cytoplasmic membrane or cause respiratory chain inhibition. Instead, acetylsalvic acid affected the cytoplasmic membrane producing leakage of 260-nm absorbing compounds.

Repeated Pap smear screening among Mexican-American women

The factors that influence repeated cervical cancer screening among Latina women are not well understood. Studies of compliance in this population over-emphasize initial or recent screening and under-emphasize how this practice is repeated over time. The purpose of this study was to identify the demographic and psychosocial factors associated with repeated Pap smear screening among low-income Mexican-American women living in two urban communities in Texas. A total of 1804 Mexican-American women were interviewed as part of a community survey. Multiple regression results indicate that demographic characteristics such as age, marital status, level of acculturation and health insurance were associated with the total number of Pap smears reported for the 5 years prior to the interview. Pap smear beliefs were the strongest predictor of repeated screening, while global beliefs about cancer did not significantly explain the results. Health promotion interventions should take into consideration the cultural and psychosocial needs of Mexican-American women, placing emphasis on their specific screening-related beliefs, if they are to succeed in promoting repeated compliance with Pap smear screening guidelines.

Sentinel monitoring of general community health during the 1998 World Football Cup

BACKGROUND

Present knowledge of the consequences of mass gatherings for the health of the community is scant. Our objective was to determine the impact of the 1998 World Football Cup on general community health.

METHODS

We set up an electronic sentinel disease surveillance, before, during and after the World Football Cup tournament held in France from June 10 to July 12, 1998. Medical activity, and the daily number of cases of communicable, environmental, and societal diseases relating to mass gatherings were surveyed. The incidence of the pathologies surveyed in real time during and after the World Cup versus the pre-Cup reference period was the main outcome measure. Five sentinel networks participated, comprising 553 general practitioners, 60 hospital adult emergency departments, 19 private emergency community services, 4 community health centres, and the medical centre of the Paris airports.

RESULTS

Throughout the 66-day study period, physicians reported 558,829 medical encounters via 21,532 connections to the computer. Compared to the reference period, the level of medical activity reflected by the pathological items surveyed remained stable during the study period.

CONCLUSION

The 1998 World Football Cup had no epidemiological impact on general community health, as observed by sentinel networks located downstream of the specific health services provided by the French authorities to ensure high standards of safety.

[Total eclipse of the sun in August 11, 1999: a program of prevention and surveillance of ocular complications]

Watching directly at the sun without appropriate protection, particularly during a solar eclipse, can cause severe retinal injuries. On 11 August 1999, a total solar eclipse crossed France. The Direction Générale de la Santé implemented a prevention strategy. A formal agreement was developed with manufacturers and importers of protective glasses and more than 30 million glasses, conformed with safety standards, were distributed in France. Information campaign reach the whole population in France. In order to evaluate the impact of this campaign, The National Institute of Public Health in France implemented a nation-wide surveillance of ocular complications related to the eclipse. Information on patients was collected using a standardised questionnaire. The questionnaire was sent to the 5,600 private and public sector ophthalmologists practising in France and to five hundred hospital emergency units. A total of 147 patients were reported to have had a retinal injury associated with viewing the eclipse. Seventeen cases were severe (visual acuity < 2/10th) of whom 7 had bilateral injury. Forty-four per cent of patients were aged 15 to 29 years and 46% viewed the eclipse in three regions in the south of France which were sunny on 11th August. One hundred and six patients (67% aged 30 years and more) presented with keratitis. Thirty-six per cent occurred in 2 northern regions of France, which were overcast on the day. A hundred patients watched the whole eclipse without any protection, 74 reported to have removed their EC glasses, and 32 used non-appropriate devices. Only 4 patients presenting with retinal injury reported having used the EC glasses the whole time whilst viewing the eclipse. France is the only country in Europe to have implemented an exhaustive prospective surveillance of ocular injuries related to the solar eclipse. According to current data, the quality and availability of EC glasses did not contribute significantly to ocular injuries. Clinical and epidemiological studies are being conducted in order to further document the evolution of patients presenting with retinal injuries, the circumstances of observation, and their comprehension of preventive messages.

Health hazards in international tourists visiting Paris in August: a five-year retrospective epidemiologic survey

BACKGROUND

Travel-related illnesses have been studied in visitors to developing countries, but no studies have examined the incidence of health problems in visitors to developed countries.

METHODS

4, 093 foreign tourists visiting Paris in August and attending to emergency medical care for acute health problems were included in an epidemiological survey conducted over 5 consecutive years. The objective was to determine what types of acute health problems occur in a foreign tourist population and to estimate the incidence of the main health hazards.

RESULTS

Gastroenteritis represented the main cause of medical care in that population (from 14.5-21.9%) followed by traumatology, ENT problem, viral syndrome and dermatology which represented altogether 60-64% of all medical problems. Two factors were related to the distribution of diseases observed: age and nationality. The monthly incidence of gastroenteritis was estimated to be between 1.33 to 2.92 per 10,000 visitors, and the overall incidence of health problems between 8 to 10 per 10,000.

CONCLUSIONS

Even if the incidence rate of gastroenteritis is low compared with developing countries, further studies are needed to support the hypothesis that gastroenteritis could be attributed to sanitary conditions in some restaurants of the French capital.

Urine benzodiazepines screening of involuntarily drugged and robbed or raped patients

OBJECTIVE

This study involved 35 patients who claimed to have been drugged before being robbed or raped, despite urine negative toxicologic screening by immunoenzymatic methods. The urines were frozen for further investigations, including enzymatic hydrolysis of urinary conjugates, liquid-solid extraction and, finally, immunoenzymatic screening of concentrated urine extract.

METHODS

Urine benzodiazepines were analyzed by immunoenzymatic assay before and after enzymatic hydrolysis combined with extraction.

RESULTS

On direct immunoenzymatic screening, 17 of the 35 urine samples were benzodiazepine positive. Enrichment of preserved specimens improved the detection threshold from 200 ng/mL to 50 ng/mL and 10 of the 18 negative urines became positive.

CONCLUSION

This method allowed us to demonstrate the benzodiazepines in half of previously negative urine samples. Benzodiazepine screening is particularly problematic because of low dosage, rapid elimination, failure to detect conjugated metabolites by immunoenzymatic reagents and high threshold of sensitivity for certain substances.

[Tuberculin reaction in healthy infants vaccinated with BCG at birth]

Tuberculin test with PPD RT-23 with Tween 80 (2 TU strength), was performed to 228 infants under two years of age. None of them had any history of contact with tuberculosis. All were healthy, well-nourished infants, and had been vaccinated with BCG at birth. A positive PPD reaction (greater than 6 mm), was found only in 8.8%, of them and 16.2% had no BCG scar on examination; 14.9% of the studied infants had negative PPD (0-5 mm) reactions together with absent BCG scars. These findings are significantly different from those previously reported by chilean authors, which showed higher proportion of positive (greater than = 6 mm) reaction to 2 TU PPD in infants from similar populations that had been vaccinated with different BCG preparations than our patients. These results suggest the need to evaluate the efficacy of the BCG vaccines that are currently being used in our country to determine the factors that may affect it and the protection that they afford.

Idiopathic thrombocytopenic purpura in patients at risk for acquired immunodeficiency syndrome. Histopathologic study, immunohistochemistry, and ultrastructural study on six spleens

Some cases of idiopathic thrombocytopenic purpura (ITP) may be related to the prodromal phase of the acquired immunodeficiency syndrome (AIDS). The morphologic features of six spleens removed in this context were studied. In the white pulp, lymphoid follicular hyperplasia was constant but hardly distinguishable from that of control ITP on routine light microscopic grounds. Moreover, its bland appearance contrasted with the major histopathologic changes usually described in lymph node biopsy specimens from patients with AIDS-related complex. Immunohistochemistry and electron microscopy demonstrated, respectively, an excess of cytotoxic-suppressor lymphocytes with a decreased CD4/CD8 ratio in the germinal centers and viral particles of the human immunodeficiency virus. The immunohistochemical and ultrastructural studies were more helpful than light microscopy in presenting histopathologic arguments in favor of the human immunodeficiency virus infection.

[B virus, delta agent and human immunodeficiency virus infections in drug addicts]

Infections with the B, D, A, NANB viruses and with the human immunodeficiency virus (HIV) are very common among drug addicts, some of whom may harbour several of these pathogens. The serum of 90 per cent of drug addicts contains one of the HBV markers, and 20 per cent of them carry an anti-D antibody which is more often present in HBs Ag-positive subjects but may also be found in those who are positive for anti-HBs and anti HBc antibodies. The presence of an anti-delta antibody increases the risk of severe histological lesions (chronic active hepatitis, cirrhosis), as does chronic alcoholism associated with drug addiction. Fifty to sixty per cent of drug addicts are seropositive for HIV. At the AIDS stage, hepatic lesions are extremely frequent (90 per cent), but they have low activity and are seldom responsible for death.

[Segmental tuberculosis of the colon manifested by rectal stenosis]

Colonic tuberculosis is currently exceptionally rare in western countries. This interesting report reminds of its existence and emphasizes the diagnostic problems with Crohn's disease in the past. The barium enema enables to show the main aspects of colonic tuberculosis, i.e. variable forms of stenosis. The contribution of colonoscopy is essential in defining the lesions and allowing multiple biopsies. These biopsies may show the presence of granulomas with caseous necrosis, and possibly the Koch Bacillus on direct examination or in culture. The conditions of prescription of the medical treatment are similar to that of other tuberculous locations. Surgery is indicated in the presence of complications, when there is a doubt the malignant nature of the lesion, finally at the stage of cicatricial stenosis.

[High prevalence of infection by hepatitis B virus and HIV in incarcerated French drug addicts]

This clinical and biological study was undertaken to assess the prevalence of infection by HIV, HBV and HDV in male drug abusers entering a prison. One hundred and thirteen drug users accepted to be tested: 14 (12 p. 100) were homosexual; 12 (11 p. 100) consumed more than 80 g per day of alcohol. The mean duration of drug addiction was 5 +/- 2.9 years; 50 (44 p. 100) declared having used a personal syringe while 63 (56 p. 100) usually shared their syringe. Serum activity of transaminases higher than twice the normal value was noted in 36 cases (32 p. 100). One hundred and two (90 p. 100) drug abusers had a HBV marker, 17 (15 p. 100) were HBs Ag carriers, 9 had anti-HBc antibody alone. The prevalence of antibodies to the HDV was 23 p. 100 and was higher among the HBs Ag carriers (65 p. 100). There were no cases of AIDS. Clinical examination showed lymphadenopathy in 49 cases (43 p. 100), a weight loss of more than 10 p. 100 in 47 cases (42 p. 100), and in 69 cases (61 p. 100), HIV positive serology, confirmed by Western blot. The duration of drug addiction was longer in the 102 drug users with HBV markers. Long duration of drug abuse and the use of a shared syringe increased the risk of HIV infection. No relation was noted between the presence of HBV markers and HIV positive serology. In this population the prevalence of HIV, HDV markers and HIV infection was high, but no relation with the duration of previous incarceration or homosexuality was found.(ABSTRACT TRUNCATED AT 250 WORDS)

Interobserver agreement in the physical diagnosis of alcoholic liver disease

Agreement among six physicians for 18 clinical signs in 50 alcoholic patients was prospectively studied. Twenty patients had alcoholic cirrhosis, 14 noncirrhotic alcoholic liver disease, and 16 alcoholics had no clinical or biochemical abnormalities. Agreement was assessed by kappa index for categorical variables and by intraclass correlation coefficient for the others. A good agreement was observed for ascites (r = 0.75) and splenomegaly (r = 0.75). It was fair for jaundice (r = 0.65), Dupuytren's contracture (r = 0.65), and vascular spiders (r = 0.64). However, it was poor for white nails (r = 0.27) and hepatic consistency (r = 0.11). Agreement was better among senior physician's than junior physicians. In order to assess which signs contributed to differentiate the three groups of patients, a stepwise discriminant analysis was realized; it identified three variables: vascular spiders (P less than 0.001), splenomegaly (P less than 0.001), and abdominal wall collateral veins (P less than 0.01). These results suggest that studies based on physical findings must be cautiously considered.

[Value of echotomography for the diagnosis of lithiasis of the common bile duct]

The accuracy of ultrasonography (US) for the diagnosis of cholelithiasis and for dilatation of the intra- and extra-hepatic biliary tree is well known. However, the value of US for the diagnosis of common bile duct stones remains poorly defined. We performed a prospective study in 100 patients who were referred for endoscopic retrograde cholangiopancreatography (ERCP); all the examinations were carried out by the same sonographist in the 24 h preceding the ERCP. Fifty patients had choledocholithiasis, 20 patients had obstruction of the bile ducts without lithiasis and the common bile duct (CBD) was free in 30 patients. The sensitivity of US for the diagnosis of choledocholithiasis was 40 p. 100, the specificity 90 p. 100. The positive and negative predictive values of the "CBD stone" sign was 80 p. 100 and 60 p. 100 respectively. In a total of 30 false negatives, the CBD could not be explored in 4 cases, dilatation of the CBD was missed in one case, and obstruction of the CBD by an other disease was diagnosed in 2; in all the other cases, US was able to appreciate the CBD size as well as the ERCP. In the 20 patients with an obstructed CBD but without choledocholithiasis, US diagnosed a stone in 5 cases. Age, serum bilirubin, existence of a previous cholecystectomy, technical difficulties, stone size were comparable in patients with true positive tests and in patients with false negative tests. However the diagnosis of choledocholithiasis was more frequently achieved in patients with dilated CBD over 10 mm (p less than 0.05) and in patients with multiple stones.(ABSTRACT TRUNCATED AT 250 WORDS)

Urinary kallikrein and plasma renin activity in normal human pregnancy

Urinary kallikrein excretion (UK), plasma renin activity (PRA), and 24-hour urine volume, sodium, and potassium excretion rates were determined sequentially in 16 normal pregnant women. Throughout gestation, UK was significantly elevated as compared to values obtained in 13 control women (1466 +/- 152 vs 375 +/- 90 U/g creatinine). The highest level was observed in Period 2 of gestation, corresponding to Weeks 17 to 24. PRA was also significantly elevated during pregnancy (11.97 +/- 1,35 vs 1.06 +/- 0.90 ng/ml/hr), with the highest level in Period 2. Mean 24-hour urine volume, sodium, and potassium excretion rates were significantly higher during pregnancy. Nor correlation was found between UK and: PRA, urine volume, and sodium and potassium excretions. These findings indicate a consistent activation of the renal-kallikrein-kinin system during pregnancy. We postulate that this vasodilator system might play a role in the maintenance of normotension in pregnancy, counteracting tha effect of the renin-angiotensin-aldosterone system.