Pathways and Intersections: Multifaceted Approaches to Engage Individuals From Underrepresented and Marginalized Communities in HIV Research and Career Development

BACKGROUND

The underrepresentation of historically marginalized groups in the HIV research workforce is a barrier to reaching national Ending the Epidemic goals.

SETTING

The Harvard University Center for AIDS Research (HU CFAR) Diversity Equity and Inclusion Working Group (DEI WG) uses a multifaceted approach to enhance the field's diversity.

METHODS

We established a DEI WG to improve the recruitment, inclusion, and retention of underrepresented minorities (URMs) in HIV research. We use community-based, participatory processes to establish and expand education and outreach programs about HIV care and research to better connect the HU CFAR to communities affected by HIV. This article reports on the development of the WG in July 2022, progress in its first year, and future plans.

RESULTS

We have built a network of >50 investigators across the university for monthly meetings; partnered with existing research pathway programs for high school, undergraduate, and graduate students, directly supporting 7 new trainees and linking CFAR investigators to additional mentorship opportunities; and created 2-year Scholar Awards for 5 URM investigators in HIV. Planned work includes needs assessments for early-stage investigators to understand factors contributing to inclusion and retention and new pathway and outreach programming being developed with community partner minority-serving institutions.

CONCLUSIONS

The HU CFAR DEI WG strives to ensure that individuals from underrepresented, marginalized, and minoritized communities have an opportunity to contribute to HIV research and that research is informed by the needs of the communities affected by the epidemic. An intersectional approach should be incorporated into HIV research pathway initiatives.

Best practices for the care of pregnant people living with TB

BACKGROUND: Each year more than 200,000 pregnant people become sick with TB, but little is known about how to optimize their diagnosis and therapy. Although there is a need for further research in this population, it is important to recognize that much can be done to improve the services they currently receive.METHODS: Following a systematic review of the literature and the input of a global team of health professionals, a series of best practices for the diagnosis, prevention and treatment of TB during pregnancy were developed.RESULTS: Best practices were developed for each of the following areas: 1) screening and diagnosis; 2) reproductive health services and family planning; 3) treatment of drug-susceptible TB; 4) treatment of rifampicin-resistant/multidrug-resistant TB; 5) compassionate infection control practices; 6) feeding considerations; 7) counseling and support; 8) treatment of TB infection/TB preventive therapy; and 9) research considerations.CONCLUSION: Effective strategies for the care of pregnant people across the TB spectrum are readily achievable and will greatly improve the lives and health of this under-served population.

Unforeseen consequences of the COVID-19 pandemic: Increased frequency of kite-string injuries in magnificent frigatebirds (Fregata magnificens) in Rio de Janeiro state, Brazil

Kite flying is a popular hobby and sport for children and adults. Despite being illegal in Rio de Janeiro state, Brazil, the use of abrasive threads remains widespread and poses a health risk to both humans and animals. In this study, we analysed the records of 462 magnificent frigatebirds ( Fregata magnificens) submitted to rehabilitation centres or found dead along the southern coast of Rio de Janeiro state from October 2016 to August 2020. Of these, 244 individuals (52.8%) presented wing lesions consistent with kite-string injury, which can have a critical impact on the ability of frigatebirds to fly and will ultimately cause their death. Even when veterinary care is provided, only a small proportion of the individuals (2%) will fully recover the ability to fly in order to be released back to the wild. In 2020, an atypical increase in the number of individuals with kite-string injuries (1,200% increase compared to other years) was noted in the weeks following the suspension of school activities and commerce in response to the COVID-19 pandemic. The number of frigatebirds with kite-string injuries recorded in a given week was positively correlated with internet searches for kite-related terms, which also peaked during the quarantine period of the COVID-19 pandemic. This illustrates how pandemic events may aggravate existing human-wildlife conflicts, and how preparedness plans need to incorporate measures to help communities cope with boredom and isolation during quarantine in ways that do not negatively impact the welfare and conservation of wildlife.

SAT0274 DESCRIPTIVE ANALYSIS OF FLARES DURING THE LONG-TERM FOLLOW-UP OF PATIENTS WITH BEHÇET’S DISEASE INCLUDED IN REGEB COHORT

Background:

Objectives:

To describe the clinical manifestations and treatment of flares during follow-up in patients with Behçet’s disease (BD) included in the REGEB cohort over the last decade.

Methods:

The Spanish Registry of BD or REGEB (REGistrode la Enfermedad de Behçet as Spanish nomenclature) Project Group was created by the Spanish Internal Medicine Society in 2009 with the aim of compiling a large cohort of Spanish patients with this rare disorder. By July 2012, REGEB has collected 635 BD patients with a multicentre, longitudinal and consecutive design. Diagnosis of BD was performed on the basis of the International Study Group criteria for BD. Since inclusion in the registry, patients have been followed prospectively and new flares have been recorded, defined as those clinical manifestations which have required initiation or modification of immunosuppressive treatment, or prednisone dose at or higher than 10mg/d of prednisone during more than 1 month.

Results:

A prospective follow-up of 326 patients included in the registry has been analysed. There are 182 women (56%) and their average age (SD) at the time of diagnosis was 33 (13) years. The majority of them were Caucasian (91%). The median follow-up time from BD diagnosis was 180 months, and the prospective follow-up period from the inclusion in the registry was 80 months. The cumulative clinical manifestations until the initial registration were oral ulcers in 100% of patients, genital ulcers in 221 (68%), arthritis in 147 (45%), erythema nodosum in 96 (29%), fever in 82 (25%), thrombosis in 74 (23%), anterior uveitis in 76 (23%), retinal vasculitis in 46 (14%), posterior uveitis in 35 (11%), aseptic meningitis in 32 (10%), and other neurological manifestations in 15 (5%) patients. One hundred and fifty-six (48%) patients received immunosuppressants and 47 (14%) biological therapy.

During follow up (period from the inclusion in the REGEB to the last visit) 68 (23%) patients presented at least a severe outbreak. The median time from the BD diagnosis to the first flare were 170 months. The main clinical manifestations were oral-genital ulcers in 43 (63%) patients, uveitis in 31 (45%), arthritis in 13 (19%), neurological in 16 (24%), vascular in 10 (15%), and gastrointestinal in 3 (4%) patients. Immunosuppressants were used in 37 (54%) patients and biological therapy in 14 (21%). Biological therapy was mostly used due to refractory disease, the majority of cases because ocular manifestations. There were no differences in terms of age, sex, race and previous clinical manifestations between patients who suffered from flares and those who did not. Flares were more frequent in patients who have received previous immunosuppressive or biological treatment (35% vs 13% and 48% vs 19%, respectively) (p<0.001 in both cases), probably reflecting a more severe disease.

Conclusion:

The long-term follow-up of BD patients from REGEB cohort showed that 10 years after diagnosis, a fifth of them may continue to present severe flares requiring systemic treatment. The use of biological therapy increased over time and their main indication was refractory disease.

Disclosure of Interests:

Mónica Rodríguez Carballeira: None declared, Roser Solans: None declared, Raquel Ríos Fernández: None declared, Begoña Escalante: None declared, Brenda Maure: None declared, Alejandra Fernández: None declared, Robert Hurtado: None declared, Rafael Boldova: None declared, Gerard Espinosa Speakers bureau: Glaxo-Smith-Kline, Janssen, Boehringer, Rovi

Effect of short-term estrogen therapy on endothelial function: a double-blinded, randomized, controlled trial

OBJECTIVE

To evaluate the effect of short-term hormone replacement therapy with 0.625 mg conjugated estrogens daily on endothelial function of healthy postmenopausal women, using flow-mediated dilation (FMD) of the brachial artery.

METHODS

We performed a double-blinded, randomized, controlled trial over 3 years. Randomization was performed using computer-generated sorting. All participants were blinded to the use of conjugated equine estrogens (CEE) or placebo and FMD was assessed by a blinded examiner, before and after 28 days of medication. A total of 64 healthy postmenopausal women were selected and randomly assigned into two groups of treatment: 0.625 mg of CEE or placebo.

RESULTS

FMD values were statistically different between the groups (p = 0.025): the group receiving CEE showed a FMD value of 0.011 compared to the placebo group (FMD = -0.082). The two groups were additionally evaluated for homogeneity through the Shapiro-Wilk test in respect to variables that could interfere with endothelial function such as age (p = 0.729), body mass index (p = 0.891), and time since menopause (p = 0.724). Other variables were excluded during selection of the participants such as chronic vascular conditions, smoking, and sedentary lifestyle.

CONCLUSION

Our results demonstrate that the administration of 0.625 mg CEE for 28 days is effective in improving vascular nitric oxide-dependent dilation assessed by FMD of the brachial artery in postmenopausal women.

CLINICAL TRIAL REGISTRATION

NCT01482416.

Short-term tibolone does not interfere with endothelial function: a double-blinded, randomized, controlled trial

Objective To evaluate the effect of short-term hormone replacement therapy with tibolone 2.5 mg daily on endothelial function of healthy postmenopausal women, using flow-mediated dilation (FMD) of the brachial artery. Methods We performed a randomized, double-blinded, placebo-controlled study. A total of 100 healthy postmenopausal women were randomly allocated to receive tibolone (n = 50) or placebo (n = 50) for 28 days. Measurement of the FMD of the brachial artery was performed before and after the use of tibolone and placebo. Results A total of 31 women completed the study in the tibolone group, and 32 women completed the study in the control group. The results of the FMD measurements obtained from the women in the two groups before treatment were similar (0.018 and 0.091, for tibolone and placebo, p = 0.57). The values of the FMD in women who used tibolone and placebo, before and after the treatment, were similar in both groups. The numbers of women who presented an increase in the values of the FMD in both groups were also similar. Conclusion Our results demonstrate that the administration of 2.5 mg tibolone to healthy postmenopausal women for 28 days does not promote endothelial-dependent vasodilation, measured by FMD of the brachial artery.

Diagnostic accuracy and clinical role of rapid C-reactive protein testing in HIV-infected individuals with presumed tuberculosis in South Africa

OBJECTIVE

To determine the accuracy and role of rapid C-reactive protein (CRP) testing in human immunodeficiency virus (HIV) infected individuals with presumed tuberculosis (TB).

DESIGN

We enrolled HIV-infected adults (≥18 years)with a cough of ≥2 weeks and negative sputum smears for acid-fast bacilli in KwaZulu-Natal, South Africa. Participants were evaluated for pulmonary TB (PTB) by a nurse with rapid CRP, and independently by a physician by chest radiograph. Rapid CRP test results were compared with laboratory CRP and sputum sent for confirmation of TB.

RESULTS

Among 93 participants, 55 (59%) were female, the mean age was 35 years, and the median CD4 count was 177/mm3. Forty-five (54%) participants were diagnosed with PTB. Diagnostic sensitivity and specificity were respectively 95% (95%CI 74–99) and 51%(95%CI 35–66) for rapid CRP >8 mg/l, 87% (95%CI 73–96) and 53% (95%CI 38–68) for nurse assessment, and 69% (95%CI 52–83) and 76% (95%CI 61–87) for physician examination. Combining a negative rapid CRP(≤8 mg/l) with nurse and physician assessments reduced the post-test probability of PTB from 22% to 6% and from 32% to 6%, respectively.

CONCLUSION

Rapid CRP testing helped exclude PTB,and may be a valuable test in assisting nurses and physicians in TB-endemic regions.

Against all odds: diagnosing tuberculosis in South Africa

Clinical and logistic systems to support the timely diagnosis of tuberculosis are currently not preventing large numbers of tuberculosis deaths in South Africa. Context-appropriate systems for the diagnosis of tuberculosis are entirely dependent on effective and responsive management of human resources and an uninterrupted supply of clinical materials. Attention to these components of the tuberculosis program is urgently needed before new diagnostic technologies can be expected to impact on tuberculosis mortality in resource constrained settings.

Eliminating the category II retreatment regimen from national tuberculosis programme guidelines: the Georgian experience

PROBLEM

The category II retreatment regimen for management of tuberculosis in previously treated patients was first introduced in the early 1990s. It consists of 8 months of total therapy with the addition of streptomycin to standard first-line medications. A review of 6500 patients on category II therapy in Georgia showed poor outcomes and high rates of streptomycin resistance.

APPROACH

The National Tuberculosis Program used an evidence-based analysis of national data to convince policy-makers that category II therapy should be eliminated from national guidelines in Georgia.

LOCAL SETTING

The World Health Organization tuberculosis case-notification rate in Georgia is 102 per 100,000 population. All patients receive culture and drug susceptibility testing as a standard part of tuberculosis diagnosis. In 2009, routine surveillance found multidrug-resistant tuberculosis in 10.6% of newly diagnosed patients and 32.5% of previously treated cases.

RELEVANT CHANGES

Category II retreatment regimen is no longer used in Georgia. Treatment is guided by results of drug susceptibility testing--using rapid, molecular tests where possible--for all previously treated tuberculosis patients.

LESSONS LEARNT

There was little resistance to policy change because the review was initiated and led by the National Tuberculosis Program. This experience can serve as a successful model for other countries to make informed decisions about the use of category II therapy.

Drug-resistant tuberculosis and pregnancy: treatment outcomes of 38 cases in Lima, Peru

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) disproportionately affects young adults, including women of childbearing age; however, treatment of MDR-TB during pregnancy is still controversial. This study looks at the treatment and pregnancy outcomes in a cohort of women who were treated for MDR-TB during pregnancy during a period of 10 years.

METHODS

A retrospective case study was performed using a standardized data collection form and data from 3 ranked sources of patient records. All 38 participants were treated during pregnancy with individualized regimens that included second-line TB medications. We examined the frequency of favorable and adverse outcomes with regard to disease and pregnancy.

RESULTS

After completion of MDR-TB treatment, 61% of the women were cured, 13% had died, 13% had defaulted, 5% remained in treatment, and 5% had experienced treatment failure. Four of the women experienced clinical deterioration of TB during pregnancy. Five of the pregnancies terminated in spontaneous abortions, and 1 child was stillborn. Among the living newborns, 3 were born with low birth weight, 1 was born prematurely, and 1 had fetal distress.

CONCLUSIONS

The rates of success in treating MDR-TB in our cohort are comparable to those of other MDR-TB treatment programs in Peru. The birth outcomes of our cohort are similar to those among the general Peru population. Therefore, we advocate that a woman should be given the option to continue treatment of MDR-TB rather than terminating pregnancy or discontinuing MDR-TB treatment.

Challenges of diagnosis and management of tuberculosis and HIV coinfection in resource-limited settings: a case report from Lima, Peru

We present a Peruvian human immunodeficiency virus (HIV)-positive patient receiving first-line therapy for tuberculosis who presents with neurological complications to highlight some of the major issues in the diagnosis and management of human immunodeficiency virus-related central nervous system complications in resource-poor settings. These include limited options for diagnosing extrapulmonary and drug-resistant tuberculosis; the importance of central nervous system . imaging; and the management conundrum when faced with a broad differential diagnosis. This patient was with drug-resistant tuberculosis of the brain, unmasked by immunologic recovery in the setting of recent initiation of antiretroviral treatment. We argue that aggressive and timely empiric multidrug-resistant tuberculosis treatment is important in cases where drug-resistant tuberculosis is suspected. Knowledge gaps include a limited understanding of immune reconstitution and the optimal timing of antiretroviral treatment in the setting of drug-resistant tuberculosis.

[Rendu-Osler-Weber disease as an infrequent cause of stroke]

INTRODUCTION

Hereditary haemorrhagic telangiectasia, or Rendu-Osler disease, is a congenital vascular disease that is associated with the presence of arteriovenous fistulas that cause paradoxical embolisms.

CASE REPORT

An 83-year-old female with clinical signs and symptoms of convulsive attacks and multiple cerebral infarctions in the acute phase. She also presented a history of multiple haemorrhages and iron deficiency anaemia with no clear aetiological causation. A thorough examination of her medical history revealed a family history of haemorrhages and a sister who had been diagnosed with Rendu-Osler disease, which suggested the possible existence of a pulmonary arteriovenous fistula as the aetiological causation of her cerebrovascular disease. Neurovascular Doppler ultrasonography with bubble contrast test was positive, and the presence of the fistula was confirmed by a computerised axial tomographic angiography scan of the lungs.

CONCLUSIONS

Rendu-Osler disease is a rare cause of stroke due to the fact that it is usually associated with arteriovenous fistulas that can cause paradoxical embolisms. Neurovascular Doppler ultrasound scanning is useful for detecting these pulmonary fistulas by means of the bubble contrast test, which is a non-invasive test that can be carried out easily by neurologists themselves.

Challenges to the success of HIV and tuberculosis care and treatment in the public health sector in South Africa

The escalating human immunodeficiency virus (HIV) and tuberculosis (TB) epidemics have had a significant impact on public health services in resource-limited settings. The province of KwaZulu-Natal in South Africa is estimated to have one of the greatest TB/HIV coinfection burdens on the African continent, coupled with historically low TB treatment success rates. In May 2004, the South African government began providing antiretroviral therapy (ART) for HIV-infected individuals within the public sector. As in many counties, this HIV treatment program was established in parallel with an existing TB treatment service. In 2005, the Integration of TB in Education and Care for HIV/AIDS (iTEACH) Program was launched in KwaZulu-Natal at Edendale Hospital. The goal of iTEACH was to identify barriers to effective treatment and develop support interventions to enable rapid expansion of access to ART and improve ART and TB treatment outcomes within the district served by this facility. In the present article, we discuss challenges to the delivery of TB and HIV care by these separate treatment programs, as well as opportunities to improve both TB treatment and ART outcomes through lessons learned during ART scale-up in the context of the HIV and TB coepidemics.

Imatinib (I) plus etoposide (Vp16) compared to I + cytarabine (Ara-C) for the frontline treatment of accelerated phase (AP) chronic myeloid leukemia (CML)

7047

Background: Higher doses than 600 mg/day of I is the most recommended initial treatment of advanced CML disease. Nevertheless clinical and molecular results are lower than on early chronic phase, challenging for new treatment developments in face to better results. Main objective of present trial was to increase the hematological (HR) and major cytogenetical responses (MCR) with the addition of Ara- C or Vp16 to I at doses higher than 600 mg/day as a frontline therapy of AP CML. Methods: on march, 2004 we began this multicentric, phase III randomized, clinical trial, comparing I (600 mg/day) plus Vp16 (50 mg PO/day for 7 days/ 21 days cycles) vs I (600 mg/day) plus subcutaneous Ara-C (10 mg/m2/day, for 7 days/21 days cycles), doses could be adjusted due to tolerance and toxicity and in case of failure to respond at 3 months, I doses could be escalated to 800 mg/day. Inclusion criteria: newly diagnosed AP (hematological or clonal evolution permitted) CML, not elective to allogeneic transplant. Primary endpoint was the acquisition and time to acquisition of HR, MCR by conventional criteria. Secondary endpoints were main toxicities, dead to progression and overall survival. Results: 35 patients were randomized with median follow-up pf 487 days (range 21–858) for entire group. Table 1 shows results for both treatment arms. Table 1 Important toxicities (more than grade II) were thrombocytopenia (20%), neutropenia (28%) and gastrointestinal disturbances (32%) for entire group. Statistical analysis for response and toxicity (chi-square, paired T-student, Log-rank survival analysis) did not show significant differences among treatment arms. . Conclusions: We can not observe significant differences among both treatment arms, but important to note is the rates of HR and MCR, suggesting than the addition of chemotherapy could decrease the leukemic burden improving the function of I. Further research is required to confirm this data.

No significant financial relationships to disclose.

[Table: see text]

A novel training model to address health problems in poor and underserved populations

Health disparities are increasingly common and many U.S. practitioners have informal experience working in resource-poor settings. There are, however, few graduate medical education programs that focus on health equity. A graduate medical education program in health equity was developed at Brigham and Women's Hospital based on a review of existing literature and on a survey of junior faculty who have had informal health disparities experience. The Howard Hiatt Residency in Global Health Equity and Internal Medicine was developed as a four-year program to provide intensive training in internal medicine and health disparities. Participating residents are matched with a mentor who has clinical and research experience in the field of global health. In addition to a series of didactic teaching sessions and longitudinal seminars that focus on issues of global health equity, residents take graduate level courses in epidemiology, health policy, ethics, and medical anthropology. Residents also carry out an independent research project in a geographic area that suffers from health disparities. Two residents are selected for training per year. Participating faculty are multidisciplinary and come from diverse Harvard-affiliated institutions. Graduate medical education in the United States with a focus on health equity is lacking. It is hoped that the novel training program in health equity for internal medical residents developed at Brigham and Women's Hospital can serve as a model for other teaching hospitals based in the United States.

Treatment of multidrug-resistant tuberculosis during pregnancy: a report of 7 cases

Multidrug-resistant tuberculosis (MDR-TB) is a global public health problem affecting women of childbearing age. Little is known, however, about the safety of the drugs used to treat MDR-TB during pregnancy. We describe 7 patients who were treated for MDR-TB during pregnancy. These patients had chronic tuberculosis that had caused extensive parenchymal damage and had high-grade resistance to antituberculous drugs. All patients received individualized antituberculous therapy prior to delivery of healthy term infants. Neither obstetrical complications nor perinatal transmission of MDB-TB was observed. One patient experienced treatment failure, and another abandoned therapy. The other 5 patients are currently cured or in treatment and have culture-negative status. In each of these 7 cases, excellent treatment outcomes were obtained for the women and their children. Under certain circumstances, MDR-TB can be successfully treated during pregnancy.

Characterization and regulation of Leishmania major 3-hydroxy-3-methylglutaryl-CoA reductase

In eukaryotes the enzyme 3-hydroxy-3-methylglutaryl CoA (HMG-CoA) reductase catalyses the synthesis of mevalonic acid, a common precursor to all isoprenoid compounds. Here we report the isolation and overexpression of the gene coding for HMG-CoA reductase from Leishmania major. The protein from Leishmania lacks the membrane domain characteristic of eukaryotic cells but exhibits sequence similarity with eukaryotic reductases. Highly purified protein was achieved by ammonium sulphate precipitation followed by chromatography on hydroxyapatite. Kinetic parameters were determined for the protozoan reductase, obtaining K(m) values for the overall reaction of 40.3+/-5.8 microM for (R,S)-HMG-CoA and 81.4+/-5.3 microM for NADPH; V(max) was 33.55+/-1.8 units x mg(-1). Gel-filtration experiments suggested an apparent molecular mass of 184 kDa with subunits of 46 kDa. Finally, in order to achieve a better understanding of the role of this enzyme in trypanosomatids, the effect of possible regulators of isoprenoid biosynthesis in cultured promastigote cells was studied. Neither mevalonic acid nor serum sterols appear to modulate enzyme activity whereas incubation with lovastatin results in significant increases in the amount of reductase protein. Western- and Northern-blot analyses indicate that this activation is apparently performed via post-transcriptional control.

Refractory anemia with excess of blasts: increased survival when treated with cyclophosphamide, methotrexate and 6-mercaptopurine

Owing to the lack of efficacious treatments for refractory anemia with an excess of blasts (RAEB), evaluation of other therapeutic strategies is necessary, especially in elderly patients. We report herein our experience with an oral triple drug regimen with cyclophosphamide 200 mg/m2 and methotrexate 20 mg/m2 once a week, and 6-mercaptopurine 50 mg/m2 daily for the treatment of RAEB. Eighteen patients with a median age of 62 yr (range 17-80) received a triple drug regimen (TDR), and they were compared with 6 patients who received oxymetholone (2 mg/m2/d) and 9 who received supportive therapy only. Partial response was achieved in 45% of patients receiving TDR. In 77% of patients treated with TDR the number of bone marrow blasts decreased to <5%; however, they persisted with trilineage dyspoietic morphologic changes. Median survival for TDR was 23 months (range 1-96), which was longer than that for the other groups. A slight rise in liver enzymes was the only side effect of TDR. TDR seems to be a useful alternative in patients with RAEB, a finding to be confirmed in further prospective studies.

Accidental radiation injury to the hand: anatomical and physiological considerations

A case study describing an accident in Mexico caused by failure to de-energize an x-ray spectrometer prior to repair is presented. The evolution, medical management, and outcome of the radiation injury to the hand are briefly reviewed. A discussion follows, with radiation injury and thermal burns compared and contrasted. The anatomy and physiology of thick skin and the vascular system of the hand are reviewed so that the reader will have a better understanding of the role of vascular injury in the pathological process that leads to tissue atrophy and radiation necrosis. Hyperbaric oxygen therapy, sympathectomy, and other techniques for improving circulation in involved areas are reviewed.

rHuGM-CSF after high-dose chemotherapy in post-remission acute leukemia

Post-remission high-dose chemotherapy has been an important advance in the treatment of adult acute leukemia (AAL). Without the use of colony-stimulating factors (CSFs) in this program, the mortality rate varies from 5 to 17%, and infectious complications arise in more than 50%. These findings limit the widespread use of such forms of therapy. The use of high-dose ara-C (HIDAC) alone or in combination with other drugs is the most common regimen studied, however neither other drug combinations nor the addition of supporting CSFs have been extensively explored. For this reason we studied the effect of high-dose cyclosphosphamide-etoposide (CECY) plus recombinant human granulocyte-macrophage (rHuGM)-CSF with the intention of decreasing morbimortality and prolonging disease-free survival (DFS). Since 1992 we have included 51 complete remission patients with AAL in the CECY plus rHuGM-CSF protocol. The maximal myelosuppression occurred in a mean of 6.4 days, and the mean days required for absolute neutrophil count recovery was 13 days and for platelets 21 days (p < 0.0001). No toxic deaths occurred and only two serious infectious complications were seen. After two years of follow-up, 50% of de novo acute myelogenous leukemia patients had relapsed at 13 months, and 50% of de novo adult acute lymphocytic leukemia patients had relapsed at 15 months. In a recent update, we have not seen a significant difference when compared to historic groups. The CECY protocol does not appear to be superior in prolonging DFS compared to HIDAC as a post-remission strategy for newly diagnosed AAL. The main difference was the absence of toxic deaths and minimal serious infectious complications in the CECY protocol. Therefore, we suggest that the use of rHuGM-CSF in post-remission programs should be included in future studies.

[Calculation of the mitral valve area with the proximal convergent flow method with Doppler-color in patients with mitral stenosis]

In this study we evaluate prospectively a new color Doppler method for calculating the mitral valve area based on identifying a blue-red aliasing interfase proximal to the orifice, corresponding to the flow convergence region (FCR). This method can be used to calculate areas using the continuity equation. We studied 61 patients with stenosis. The mitral valve area was calculated using pressure half-time (PHT) Doppler method which were compared with values that obtained by the FCR method, according to the following formula. AVM (cm2) = 2 pi r2 x VN/Vmax; where "r" is the FCR radius measured from the orifice to the first color aliasing (blue-red interface); VN is Nyquist velocity and Vmax is the peak flow velocity by continuous wave Doppler. Twenty three patients had pure mitral stenosis and 38 double mitral lesion. Twenty patients were on sinus rhythm while 41 in atrial fibrillation. Calculated mitral valve area using the FCR method correlated well with mitral valve area determined by PHT method at a correlation coefficient of r = 0.96 (y = 0.097 x + 54.9, SEE = 0.10 cm2, p < 0.001). MVA by FCR ranged from 0.4 to 2.5 cm2 (mean = 1.19 cm2). MVA by PHT ranged from 0.42 to 2.48 cm2 (mean = 1.15 cm2). Color Doppler FCR method provides an accurate estimate of effective mitral valve area and may be useful as an alternative to the pressure half-time method. The calculated mitral valve area by the FCR method is not influenced by the presence of mitral regurgitation nor atrial fibrillation.

Drug-induced agranulocytosis treated with granulocyte-macrophage colony stimulating factor

Drug induced agranulocytosis (DIA) is a potentially lethal disorder characterized by selective neutropenia. Granulocyte-macrophage colony-stimulating factor (GM-CSF) has been utilized for its treatment. We report four cases of DIA treated with GM-CSF at the dose of 5 micrograms/kg/day. The patients presented infectious diseases at diagnosis. Median days to obtain 1 x 10(9)/L neutrophils and a normal neutrophil count (NNC), were 7(5-9) and 7.5 (6-10) days, respectively. The infectious disease at diagnosis improved and all patients are alive at the moment of this report. No other adverse effects than thrombocytosis (two cases) and thrombocytopenia (one case) were observed. We consider that GM-CSF could be a safe and effective alternative in the treatment of DIA.

[Nonselective angiography of the internal mammary artery--improved imaging by simultaneous compression of the ipsilateral brachial artery]

Because of the increasing use of the internal mammaria artery (IMA) in bypass grafting pre- and postoperative angiography of the artery is more often necessary. Selective IMA angiography is frequently difficult and time- and fluoroscopy-consuming. Therefore, different procedures of nonselective angiography have been developed. We report on the improved nonselective visualization of the IMA by manual injection in the subclavian artery and simultaneous ipsilateral compression of the brachial artery by inflating a blood pressure cuff above systolic blood pressure. Thereby a reduction of fluoroscopy time is possible without significant loss of diagnostic information.

[Liver transplantation in Mexico. Report of the first successful case]

This article reports the first successful human orthotopic liver transplantation performed in Mexico. The recipient was a 41 year old white male, with a history of essential hypertension and hepatitis in 1975. The diagnosis of postnecrotic cirrhosis was made in 1985 by liver biopsy. The HBsAg was negative and the functional reserve of the liver was limited (Stage "C" of the Child-Pugh classification). A liver graft was obtained through the National Cadaver Organ Transplant Program on May 2, 1988 and an orthotopic liver transplantation was performed without incidents, using the portosystemic veno-venous bypass. Inmunosuppression was carried out with triple drug therapy, cyclosporine, azathioprine, and prednisone. His postoperative course was characterized by idiopathic cholestasis, one episode of acute rejerction, arterial hypertension, renal dysfunction, esophageal herpes and inguinal lymphocele, all of which resolved. Currently the patient is alive 22 months postransplantation with normal liver function and adequate quality of life.

Diagnostic laparotomy in fever of unknown origin

Twenty five consecutive patients with fever of unknown origin (FUO) who underwent diagnostic laparatomy (DL) are reviewed. There were 14 females and 11 males, with a mean age of 34 years. The main symptoms and signs besides fever were malaise, weight loss, varied abdominal complaints, peripheral lymph nodes enlargement, hepatomegaly and splenomegaly. The main laboratory abnormalities were: anemia, leukocytosis, and mild alterations in liver function tests. CT scan was performed in 14 patients: hepatomegaly, splenomegaly and or retroperitoneal nodes were found in 10 of them. During laparotomy, an extensive exploration of intra-abdominal organs was performed, taking multiple biopsies for histopathologic and microbiologic analysis. Splenectomy was performed in 17 patients, prophylactic appendectomy in four, and cholecistectomy in one. Laparotomy was useful to establish a diagnosis in 64 percent of cases. The most frequently diagnosed pathologies were lymphoma and tuberculosis. Postoperative morbidity was 12% and mortality was 4%. Mean follow-up was 29 months. When preoperative data were analyzed, no predictive factors were found for a laparotomy with diagnostic success. It is concluded that DL is a useful last-step procedure in the diagnostic work-up for patients with FUO.

[Seroprevalence of viral markers of hepatitis B among health professionals. Multicenter study in Mexico]

To determine the prevalence of serological markers for hepatitis B infection among health care workers (HCW) in Mexico we surveyed 1072 volunteers from 26 hospitals in 12 states, from which only 1017 fulfilled the inclusion criteria: 82 patients (8.1%) were excluded because of lipemic and/or hemolyzed serum, leaving 935 persons in the study. The study population consisted of physicians, nurses, laboratory chemists, health laboratory technicians and odontologists. All of them had been working in their respective fields and in contact with biological materials for at least 12 months. None of them had been vaccinated for hepatitis B. We determined the presence of HBsAg and anti-HBs by the ELISA method. The participants' mean age was 31.4 years (range: 18-72) and their mean working time was 7.8 years. 615 were female and 320 male. The HBsAg was positive in 11 (1.2%) and the anti-HBs in 91 cases (9.7%). These results suggest that HCW in Mexico have a greater relative risk of becoming infected with the HB virus than the general population. Relative risks were particularly higher for the health laboratory technicians and the physicians. These results confirm that biohazard measures must be reinforced and that the application of HB virus vaccine could be recommended for health care workers.

Deficiency of protein C in patients with portal vein thrombosis

Portal vein thrombosis has been considered idiopathic in 50% of cases reported in adults. Protein C deficiency is a recently described disorder characterized by a predisposition to develop thromboembolic disease. We report the findings in two patients with portal hypertension and bleeding varices due to portal vein thrombosis in whom a deficiency of protein C was present. Both cases were very similar, with a history of recurrent episodes of systemic thromboembolic disease, mesenteric venous thrombosis that required intestinal resection and upper gastrointestinal bleeding from gastroesophageal varices. Portal hypertension as well as portal vein thrombosis were demonstrated. The hematologic work-up revealed a deficiency of protein C. Both patients were subjected to the Sugiura procedure, and anticoagulation was instituted thereafter. At the time of surgery, a liver biopsy was performed, which was reported as "normal." Two years and 3 months, respectively, after surgery both patients are in good condition. We conclude that protein C deficiency should be investigated in all cases of portal vein thrombosis, especially in those with a history of thromboembolic disease elsewhere.

[Circadian rhythm in myocardial infarct]

In order to determine if the beginning of the Myocardial Infarction (MI) is at random along the day or if it follows a circadian rhythm, we analyzed the clinical charts of 819 patients admitted to the Coronary Care Unite. Among them, 645 were male and 174 female. It was established that the beginning of the MI follows a circadian rhythm with maximal frequency between 8 and 9 a.m. and minimal at 0 hours (p greater than 0.01). This rhythm is sex independent. In patients younger than 45 years as well as those who received beta-block agents in less than 24 hours previous the MI no circadian rhythm was observed.

[Simplified correction factor for the calculation of heart ventricle volume by angiography]

To measure cardiac volumes from the cineventriculographic silhouette, a calibration factor (fc) is needed to correct the X rays' distorsion and amplification. In the past, several methods have been described in order to obtain this fc, whose determination is often trouble-some, and time consuming, because of the necessity of planimetry, and calibration grid use. In this paper, we describe a method to calculate the fc: after RAO left ventriculography was obtained, a metalic sphere, whose diameter is well known, is filmed at the same incidence and distance of the left ventricle from the X ray tube and image intensifier. A good correlation was found when ventricular volumes estimated by the sphere, plannimetry of a grid, and ellipsoid axes measuring methods were compared (p less than 0.01). Methodology of the three procedures is being discussed and sphere method is recommended, because it avoids the grid use or planimetry performance and because it makes easier the fc determination.

[Total situs inversus associated with Lutembacher syndrome]

We describe a 19 years old patient with total situs inversus in association with Lutembacher's syndrome, and surgical intervention. Our review of the literature, did not disclosed any similar case.

[Changes in ventricular function in diabetes mellitus. Relation to the duration of the diabetes and its complications]

To find out if ventricular dysfunction is related with diabetes duration or diabetic chronic complications, resting and exercise electrocardiograms, chest X-ray, echocardiograms and dynamic scintigraphy with left ventricular ejection fraction measurement (LVEF) were performed to three groups of diabetic subjects without known cardiopathy or hypertension: (I) twelve subjects with less than five-years diabetes, (II) eleven with five to ten years, (III) nineteen with diabetes lasting more than ten years. Results were compared with ten healthy volunteers. 90.4% of diabetics had at least one abnormality. LVEF was significantly lower in diabetics (P less than 0.001) than in control group. No important differences were found according to diabetes duration. Lower fractional shortening and lower cardiac output were found in group III than in control group (P less than 0.05). Impaired ventricular function in group III was related (P less than 0.05) with the evidence of diabetic late complications. Relationship between ventricular dysfunction and other microvascular abnormalities might suggest that microangiopathy participates in some extent to the pathogenesis of ventricular disorder.

Is it possible to maintain a normal glutathione level in lenses in vitro?

In most types of experimentally induced cataracts, glutathione (GSH) content decreases considerably before the onset of opacity. GSH may provide a protective function for protein SH groups by scavenging oxidative products that may impair lens metabolism. To avoid impairment of lens metabolism by decreased levels of GSH it may be possible in vitro: (1) to stimulate GSH synthesis by enrichment of the incubation medium with the amino acids necessary for GSH synthesis or (2) to enrich the incubation medium with the tripeptide itself so that it can be taken up by the lens. Both approaches were investigated with bovine lenses. Lenses were incubated in pairs in a salt solution without carbohydrates, so as to deplete lens of GSH. Following starvation, one lens of each pair was incubated for recovery in TCM 199 enriched with MgSO4 and the three amino acids of GSH; the other lens was put into a freshly prepared salt solution. After 6 h, lenses from the recovery solution contained more GSH than the other lenses. Addition of fructose-1,6-diphosphate to the medium enhanced this effect. When, after starvation, lenses were incubated in the presence of different amounts of GSH, GSH lens content rose, with the highest in those lenses incubated in a medium with a final molarity of 4 X 10(-3) M GSH. Therefore, incubation of lenses depleted of GSH in medium with either the amino acids of GSH or GSH itself appear to facilitate recovery of GSH content.

[Marfan syndrome and echocardiography]

We report the echocardiographic features of nine patients with Marfan syndrome. Six men and three women. Average age: twenty nine years. Sixty six per cent had aneurysmatic enlargement of the aortic root. One hundred per cent of the cases had aortic insufficiency, enlargement of the left ventricular diameter, decrease of the ejection fraction, and decrease in circunferential shortening; mitral prolapse, (in 6) and signs of high pulmonary artery pressure (in 4 cases). Hemodynamic studies performed in 46 per cent of the patients correlated well with the echocardiographic features. Autopsy performed in the patients who died, corroborated the cardiovascular abnormalities. We conclude that the use of the echocardiogram is a useful non-invasive technique for the early evaluation of the cardiovascular features in the Marfan syndrome.

Hemocytopenia as initial manifestation of systemic lupus erythematosus. Prognostic significance

In 1960 Rabinowitz and Dameshek emphasized the close relationship between idiopathic thrombocytopenic purpura (ITP) and systemic lupus erythematosus (SLE) and suggested that ITP is often a prodrome of SLE. On the basis of tis observation, the present study was designed to investigate the prevalence of SLE in patients with the initial diagnosis of ITP, autoimmune hemolytic anemia (AIHA), Fisher-Evans' syndrome (F-E) and idiopathic aplastic bone marrow (IABM) and to investigate the salient clinical manifestations and prognosis of these patients. We studied 62 patients, 35 with ITP, 16 with AIHA, 9 with F-E and 2 with IABM. Seventeen developed four or more ARA criteria for SLE within 6 of 14 years after the initial hematologic manfestations (IHM). Mucocutaneous symptoms predominated in all groups. None developed renal failure and only 2 had central nervous system involvement. When these patients were matched by age, sex and duration of illness with 24 SLE patients without hematologic abnormalities, the everity and therapeutic indices of the former showed a significantly (p 0.001) milder course. Eight of the 9 patients that required splenectomy are at present without treatment. SLE patient with IHM have a more benign course which is not worsened by splenectomy.