Role of β-blockers in the cardiovascular disease continuum: a collaborative Delphi survey-based consensus from Asia-Pacific

OBJECTIVE

This Delphi method of consensus was designed to develop scientific statements for β-blockers in the continuum of cardiovascular diseases with a special focus on the role of bisoprolol.

METHODS

Eleven experienced cardiologists from across the Asia-Pacific countries participated in two rounds of the survey. In the first round, experts were asked to rate agreement/disagreement with 35 statements across seven domains regarding the use of β-blockers for treating hypertension, heart failure, coronary artery diseases, co-morbidities, as well as their safety profile, usage pattern, and pharmacokinetic variability. A consensus for a statement could be reached with >70% agreement.

RESULTS

Except for seven statements, all attained consensus in the first round. In the second round that was conducted virtually, the experts re-appraised their ratings for the seven statements along with a critical appraisal of two additional statements that were suggested by experts in the preceding round. At the end of the second round, the final version included 36 statements (34 original statements, two statements suggested by experts, and the omission of one statement that did not attain consensus). The final version of statements in the second round was disseminated among experts for their approval followed by manuscript development.

CONCLUSION

Attainment of consensus for almost all statements reconfirms the clinical benefits of β-blockers, particularly β1-selective blockers for the entire spectrum of cardiovascular diseases.

Renal function and the effects of vericiguat in patients with worsening heart failure with reduced ejection fraction: insights from the VICTORIA (Vericiguat Global Study in Subjects with HFrEF) trial

Aims

Vericiguat reduced the primary composite outcome of cardiovascular death or heart failure (HF) hospitalization in patients with worsening HF with reduced ejection fraction (HFrEF) and a lower limit of baseline estimated glomerular filtration rate (eGFR) of 15 mL/min/1.73 m². We evaluated the relationship between the efficacy of vericiguat and baseline and subsequent changes in renal function.

Methods and results

In VICTORIA, core laboratory serum creatinine was measured at baseline (n = 4956) and weeks 16, 32, and 48. Worsening renal function (WRF), defined as an increase ≥0.3 mg/dL in creatinine from baseline to week 16, was assessed via a Cox model with respect to subsequent primary events. Mean age was 69 years, 24% were female, and mean baseline eGFR was 61 mL/min/1.73 m². During 48 weeks of treatment, the trajectories in eGFR and creatinine with vericiguat were similar to placebo (P = 0.50 and 0.18). The beneficial effects of vericiguat on the primary outcome were not influenced by baseline eGFR (interaction P = 0.48). WRF occurred in 15% of patients and was associated with worse outcomes (adjusted hazard ratio 1.28, 95% confidence interval 1.11–1.47; P < 0.001), but the beneficial effects of vericiguat on the primary outcome were similar in patients with or without WRF (interaction P = 0.76).

Conclusion

Renal function trajectories were similar between vericiguat‐ and placebo‐treated patients and the beneficial effects of vericiguat on the primary outcome were consistent across the full range of eGFR and irrespective of WRF.

Quantitative analysis of myocardial metabolic heterogeneity is superior to visual assessment for the detection of active cardiac sarcoidosis by F-18 FDG PET-CT imaging

Funding Acknowledgements

Type of funding sources: None.

Background

Myocardial inflammation may occur in the context of a multisystem disease such as sarcoidosis, adversely affecting prognosis. A definitive diagnosis of cardiac sarcoidosis (CS) is essential to implementing life-saving treatment but this is complicated by the invasive nature of endomyocardial biopsy (EMB) and its low accuracy. Positron emission tomography (PET) assists in diagnosis, which relies on visual interpretation of myocardial F-18 FDG uptake. The value of quantitative analysis and its application to clinical practice remain uncertain.

Purpose

To investigate the power of quantitative F-18 FDG PET-CT imaging analysis for detecting CS in patients with suspected disease.

Methods

All patients underwent F-18 FDG PET-CT after a 24-hour low-carbohydrate diet and 15-hour fasting as part of their diagnostic work-up for suspected cardiac inflammation. Cardiovascular magnetic resonance acted as gatekeeper to PET-CT in 8 of every 10 scans. Myocardial F-18 FDG uptake was assessed qualitatively and quantitatively using both manually drawn regions of interest and automatic polar maps to measure global and segmental standardised F-18 FDG uptake values (SUV).  The coefficient of variation (CoV) was calculated to determine uptake heterogeneity. To confirm diagnosis, follow-up data regarding disease progression, further testing and treatment were collected. To allow for sufficient follow-up time, the first 40 consecutive patients from a prospective registry (n= 214; Sep 2017-Jun 2020) were included.

Results

A comprehensive clinical picture was obtained successfully in 37 patients (median [IQR], 17 [13.5] months) and a final diagnosis of CS reached in 7 (disease prevalence, 19%). EMB was performed in 2 patients only while 3 underwent PPM/ICD implantation. Significant predictors of CS were fulfilment of Japanese Ministry of Health and Welfare criteria (Wald, 6.44; p = 0.01) and left ventricular dysfunction (Wald 6.72; p = 0.01). Qualitative F-18 FDG PET-CT had a high negative (95%) but low positive (45%) predictive value for CS (sensitivity, 83%; specificity, 77%). F-18 FDG SUV CoV was the strongest imaging predictor (Wald, 6.77; p = 0.009) and was significantly higher in CS than non-CS (CoV median [quartiles], 0.26 [0.21, 0.36] and 0.12 [0.11, 0.14] respectively; p = 0.004). As per ROC curve analysis (AUC, 0.84), a CoV threshold of 0.20 was highly specific (93%) and sensitive (86%) for CS.

Conclusion

In a referring population with a low prevalence of cardiac sarcoidosis, F-18 FDG PET-CT imaging is sensitive for the detection of myocardial inflammation with active disease unlikely in patients with a negative scan. Quantitative evaluation of metabolic heterogeneity within the myocardium provides a strong, independent marker of active disease and should be considered alongside visual assessment.

A bioinspired metal-organic approach to cross-linked functional 3D nanofibrous hydro- and aero-gels with effective mixture separation of nucleobases by molecular recognition

The direct reaction between Cu(CH3COO)2 and uracil-1-acetic acid in water gives rise to the formation of a hydrogel consisting of entangled nanometric ribbons of a crystalline antiferromagnetic 1D Cu(ii) coordination polymer (CP) decorated with biocompatible uracil nucleobases. This hydrogel is the precursor for the preparation of a meso/macroporous ultralight aerogel that shows a remarkable Young's modulus. As a proof-of-concept of the molecular recognition capability of the terminal uracil moieties anchored at Cu(ii) CP chains, this material has been tested as the selective stationary phase for the separation of nucleobase derivatives in HPLC columns.

Influence of Acculturation on Emotional Learning and Memory in Spanish and English Speakers

Objective

The Emotional Verbal Learning Test-Spanish (EVLT-S) is a novel list learning test similar in structure to traditional verbal memory tests but contains words from 4 discrete emotional categories. Influence of acculturation on emotional learning was examined on EVLT-S learning trials 1 to 5.

Participants and Method

Participants included 50 bilingual healthy individuals in the Spanish-dominant group (Age M = 20.3years; 72% female) and 27 in the English-dominant group (Age M = 23.4years, 51.9% female). They were administered a battery of tests including the EVLT, a non-emotional verbal list learning test (LLT), Vocabulary (VC), Digit Span (DS), and The Short Acculturation Scale for Hispanics (SASH) in their dominant language. To examine learning curves a mixed model ANOVA was conducted with test (EVLT-S/EVLT, LLT-S/LLT) and trial as within-subjects variables and group (Spanish, English) as a between-subjects variable.

Results

There were significant main effects (p &lt; .005) for test, trial, and group. The Spanish-dominant group had the lowest overall performance on the EVLT-S (main effect for group). Post hoc comparisons of the Spanish-dominant group’s LLT-S and EVLT-S performance indicated significant differences at each trail (p &lt; .01), with the EVLT-S scores being lower than the LLT-S scores. The ANOVA was repeated with VC, DS, and SASH included as covariates. When controlling for these variables, the main effect for group was no longer significant. A significant trial by acculturation interaction effect emerged (p&lt;.05), with the English-dominant group generally performing better than the Spanish-dominant group.

Conclusions

Results suggest that Spanish and English language group differences were largely accounted for by word knowledge (VC), working memory (DS), and acculturation differences (SASH) between the groups. The role of these variables is discussed further in the context of acculturation.

Factorial Validity of the Emotional Verbal Learning Test-Spanish (EVLT-S)

Objective

The EVLT-S is the Spanish translation of a novel measure of emotional verbal learning and memory. The current study aimed to preliminarily examine the factorial validity of the EVLT-S to determine if its latent structure was similar to that identified for the EVLT by Strauss and Allen (2013) in a sample of 329 English speakers.

Participants and Method

Two principal component analyses (PCAs) were conducted to examine the latent structure of the EVLT-S. The first PCA examined EVLT/EVLT-S performance in a combined sample of English language-dominant participants (n = 52; Age M = 23.1 years; Education M = 13.4 years; 32.7% White non-Hispanic, 36.5% Hispanic, and 30.8 % other; 55.8% female) and Spanish language-dominant participants (n = 50; Age M = 20.3 years; Education M = 12.8 years; 98% Hispanic and 2% other; 72% female). The second PCA was conducted with the Spanish dominant sample alone (n = 50). PCAs were conducted using comparable scores and procedures reported by Strauss and Allen (2013), including scores for the four emotion categories (happiness, sadness, anger, anxiety), varimax rotation, and Kaiser-Guttman criteria to determine the number of components, allowing for direct comparisons between the current results and those previously reported.

Results

Both PCA’s identified five components that accounted for 68.6 – 70.4 percent of the variance and attained simple structure. Based on factor loadings, these components were labeled Anger, Sadness, Happiness, Anxiety, and Short-Term Memory (STM).

Conclusions

The PCA analyses in this study were exploratory in nature but were remarkably consistent with prior results attained in a much larger sample (n = 329) of English speakers. Results provide preliminary support for a stable and generalizable EVLT latent structure in Spanish and English versions. Future studies with larger samples using confirmatory factor analyses are needed to further establish the factorial validity of the EVLT-S.

References

Strauss, G. P., & Allen, D. N. (2013). Emotional Verbal Learning Test: development and psychometric properties. Archives of clinical neuropsychology, 28(5), 435-451.

A comparison of 3 on-line nomograms with the detection of primary circulating prostate cells to predict prostate cancer at initial biopsy

INTRODUCTION

The use of nomograms which include the PSA may improve the predictive power of obtaining a prostate biopsy (PB) positive for cancer. We compare the use of three on-line nomagrams with the detection of primary malignant circulating prostate cells (CPCs) to predict the results of an initial PB in men with suspicion of prostate cancer.

METHODS AND PATIENTS

Consecutive men with suspicion of prostate cancer underwent a 12 core TRUS prostate biopsy; age, total serum PSA, percent free PSA, family history, ethnic origin and prostate ultrasound results were used for risk assessment using the online nomograms. Mononuclear cells were obtained by differential gel centrifugation from 8ml of blood and CPCs were identified using double immunomarcation with anti-PSA and anti-P504S. A CPC was defined as a cell expressing PSA and P504S and defined as negative/positive. Biopsies were classified as cancer/no-cancer. Areas under the curve (AUC) for each parameter were calculated and compared and diagnostic yields were calculated.

RESULTS

1,223 men aged>55 years participated, 467 (38.2%) had a biopsy positive for cancer of whom 114/467 (24.4%) complied with the criteria for active observation. Area under the curve analysis showed CPC detection to be superior (p<0.001), avoiding 57% of potential biopsies while missing 4% of clinically significant prostate cancers.

CONCLUSIONS

The CPC detection was superior to the nomograms in predicting the presence of prostate cancer at initial biopsy; its high negative predictive value potentially reduces the number of biopsies while missing few significant cancers, being superior to the nomograms in this aspect. Being a positive/negative test the detection of CPCs avoids defining a cutoff value which may differ between populations.

Cryptomphalus aspersa mollusc eggs extract promotes migration and prevents cutaneous ageing in keratinocytes and dermal fibroblasts in vitro

BACKGROUND

The search of substances that minimize cutaneous ageing has increased in the last few years. Previous studies have described the regenerative properties of the secretion of the mollusc Cryptomphalus aspersa (C. aspersa) when applied topically.

OBJECTIVE

We evaluate the in vitro effects of a new product derived from the eggs of C. aspersa, IFC-CAF, on cell proliferation, migration, distribution of cytoskeletal proteins, production of extracellular components as well as its ability to prevent cutaneous ageing because of intrinsic or extrinsic factors (exposure to UVB) by determination of ageing markers.

METHODS

We have used the human keratinocyte cell line (HaCaT cells), primary dermal fibroblasts (HDF) and senescent dermal fibroblasts (SHDF). The effects of the compound on cell proliferation and on the cell cycle were determined by the MTT colorimetric assay, estimation of total protein and/or trypan blue test and by flow cytometry, respectively. We also studied cell migration using the wound-healing migration assay, whereas ELISA assays, Western Blot and immunofluorescence microscopy were carried out to test the expression of proteins related to cytoskeleton, extracellular matrix and with ageing.

RESULTS

We have found that IFC-CAF does not promote proliferation but induces migration of HaCaT, HDF and SHDF in a time- and dose-dependent manner; a better organization of cytoskeletal proteins (F-actin and vimentin) and promotes the production of extracellular components (fibronectin, collagen 1 and MMPs) and the adhesion to cell-substrate vinculin protein. IFC-CAF also prevents cutaneous ageing. The treatment decreases the expression of the ageing-related markers b-Gal, p53 and p16INK4 in SDDF cells, and improves cell survival after UVB irradiation and nuclear repair in HaCaT cells.

CONCLUSION

IFC-CAF has regenerative properties and protects against ageing factors being, therefore, a potential therapeutic agent for treating or preventing skin ageing.

Particle size distribution and its relationship to black carbon in two urban and one rural site in Santiago de Chile

The size distribution of particles has been studied in three sites in the Metropolitan area of Santiago de Chile in the winter of 2009 and a comparison with black carbon was performed. Two sites are located near busy streets in Santiago and the other site is located in a rural area about 40 km west of Santiago with little influence from vehicles, but large influence from wood burning. The campaign lasted 1 or 2 weeks in each site. We have divided the particle size measurements into four groups (10-39 nm, 40-62 nm, 63-174 nm, and 175-700 nm) in order to compare with the carbon monitor. In the sites near the street, black carbon has a high correlation (R = 0.85) with larger particles (175-700 nm). The correlation decreased when black carbon was compared with smaller particles, having very small correlation with the smallest sizes (10-39 nm). In the rural site, black carbon also has a high correlation (R = 0.86) with larger particles (175-700 nm), but the correlation between black carbon and the finest particles (10-39 nm) decreases to near 0. These measurements are an indication that wood burning does not generate particles smaller than -50 nm. In the urban sites, particle size distribution is peaked toward smaller particles (10-39 nm) only during rush hours, but at other times, particles size distribution is peaked toward larger sizes. When solar radiation was high, evidence of secondary particle formation was seen in the rural site, but not in the urban sites. The correlation between the number of secondary particles and solar radiation was R2 = 0.46, indicating that it there may be other variables that play a role in ultrafine particle formation. Implications: A study of the size distribution of particles and black carbon concentration in two street sites and one rural site shows that in the last site the number of particles ultrafine particles (d < 40 nm) is 10 times lower but the number of larger particles is about 2 times lower. Thus, the rural site has less of the particles that are more dangerous to health. The number ofultrafine particles is mostly associated with traffic, while the number of larger particles is associated with wood burning and other sources. Wood burning does not generate particles smaller than -50 nm.

Clinical and echocardiographic profile and outcomes of peripartum cardiomyopathy: the Philippine General Hospital experience

BACKGROUND

Peripartum cardiomyopathy (PPCM) is a rare disease entity of unknown aetiology. High rates of mortality or poor overall clinical outcome are reported in women with this condition. Certain characteristics are risk factors for this disease. In Asia, there are limited data, especially in the Southeast Asian region. In the Philippines, no data exist regarding the prevalence or risk factors.

OBJECTIVES

To determine the prevalence, profile and outcomes of PPCM in Philippine General Hospital and to describe their echocardiographic findings.

METHODS

All patients diagnosed with PPCM in the period of 1 January 2009-31 December 2010 were seen and examined. Demographic data and echocardiogram of the patients were reviewed.

RESULTS

9 were diagnosed with PPCM during the study period. The prevalence is 1 in 1270 live births. Mean age was 29. 78% presented with moderate to severe heart failure symptoms in the prepartum period. Among purported risk factors for PPCM, obesity, multiparity and pre-eclampsia were seen in most. Conversely, only one patient admitted to having more than a single sexual partner. Only one patient had multifetal pregnancy. None were smokers. 44% underwent caesarean section for maternal indication. No mortality was seen. Fetal outcomes were good with all resulting in live births and most were appropriate for gestational age. Echocardiographic findings showed global wall motion abnormalities in the majority, mean ejection fraction of 34% and mean fractional shortening of 20%.

CONCLUSIONS

PPCM is rare in the Philippines. Compared with international data, our patients are younger with low percentages of promiscuity, multifetal pregnancy, smoking history and tocolytic use. Similar to previous studies, obesity, multiparity and pre-eclampsia were also present in our PPCM patients. Immediate maternal and fetal outcomes were generally good. Adherence to standard heart failure management is high.

Effect of androgen blockade on HER-2 and matrix metalloproteinase-2 expression on bone marrow micrometastasis and stromal cells in men with prostate cancer

INTRODUCTION

HER-2 has been associated with castrate resistant prostate cancer and matrix metalloproteinase-2 (MMP-2) in the dissemination and invasion of tumor cells as well as activating angiogenesis. We present an immunocytochemical study of the effect of androgen blockade on the expression of HER-2 and MMP-2 in bone marrow micrometastasis and the surrounding stromal cells in men with prostate cancer.

METHODS AND PATIENTS

A cross-sectional study of men with prostate cancer. Touch preps were obtained from bone marrow biopsies of men with prostate cancer, before and after radical prostatectomy and during androgen blockade. Micrometastasis detected with anti-PSA immunocytochemistry underwent processing with anti-HER-2 and anti-MMP-2 immunocytochemistry. Patients were defined as HER-2 positive or negative, MMP-2 negative or an MMP-2 pattern described as border or central and stromal MMP-2 defined as positive or negative. The expression of the biomarkers was compared before and after primary treatment and during androgen blockade in relation to the serum PSA at the time of sampling and duration of androgen blockade.

RESULTS

191 men participated, 35 men before surgery and 43 after surgery; there were no significant differences in HER-2 expression between groups, there was no MMP-2 expression centrally or stromal expression of MMP-2. In men with androgen blockade, HER-2 expression was significantly higher; there was a trend for increasing HER-2 expression up to 5 years; central MMP-2 expression significantly increased after 3 years, while stromal MMP-2 significantly increased after 6 years. MMP-2 expression both in micrometastasis and stroma was significantly associated with HER-2 expression. Expression of MMP-2 at the border of the micrometastasis was not associated with HER-2 expression and occurred in the absence of androgen blockade.

CONCLUSIONS

Androgen blockade decreases serum PSA by eliminating HER-2 negative prostate cancer cells. However, there is early selection of HER-2 positive cancer cells which leads to androgen independence and to increased expression of MMP-2 activity in the micrometastasis. The increased MMP-2 activity in the micrometastasis increases the expression of MMP-2 in the surrounding stromal cells and thus could promote angiogenesis and tumor growth resulting in macrometastatic androgen independent disease.

A performance analysis of the presence of malignant circulating prostate cells as a predictive factor for the detection of prostate cancer in the first, second and third prostate biopsy

OBJECTIVES

Serum prostate specific antigen and digital rectal examination are the tests used as screening tests to detect prostate cancer. However, only approximately 30% of men with suspicion of cancer have it confirmed on prostate biopsy, and not all of these need treatment. Detection of circulating tumor cells in localized prostate cancer has given variable results, but it could be a useful complementary screening tool to detect prostate cancer in men with abnormal screening tests before the evaluation with prostate biopsy. This may be more so in subsequent biopsies where serum PSA has a decreased diagnostic yield. To evaluate the diagnostic yield of the detection of CPCs as a complementary PC screening test in a population fulfilling criteria for an initial, second and third prostate biopsy for suspicion of PC.

METHODS

A prospective screening study of consecutive patients aged 45-80 years presenting to the urologist for PC screening. Inclusion criteria were PSA >4.0 ng/ml, PSA velocity >0.35 ng/ml/year and/or DRE suspicious for cancer. Patients fulfilling inclusion criteria had blood taken for CPC detection and then underwent 12-core transrectal prostate biopsy. Double immune-his-tochemical staining with anti-PSA and anti-P504S was used to detect CPCs. Both cytologist and pathologist were blinded to the results of the biopsy, CPC results and clinical details. The diagnostic yield of the presence or absence of CPC was evaluated; the prostate biopsy was classified as cancer or no-cancer.

RESULTS

282 men participated, 83 undergoing of these undergoing a second and 38 a third biopsy, with a mean age of 66.2 ± 8.9 years and a median serum PSA of 5.10 ng/ml, 5.45 ng/ml and 6.45 ng/ml for first, second and third biopsies. Cancer was detected in 33,6%, 10.8% and 29.0% of first, second and third biopsies respectively, CPCs were detected in 36.9%, 21.7% and 36.8% of the patients. Sensibility, specificity and negative predictive value were 86% ,91% and 94% for the first biopsy, 89%, 87% and 99% for the second and 100% , 89% and 100% for third biopsy respectively. All the CPC determinations were interpretable. There were 11 false negative cases, all with small low grade tumors. Of the 29 men with a false positive CPC, 8/10 had cancer detected in the subsequent biopsy.

CONCLUSIONS

The use of CPC detection could be useful as a complementary prostate cancer screening test, especially for excluding cancer, and including patients with indications for repeat biopsies. Men with a false positive CPC detection had a high risk of detecting cancer in the succeeding biopsy.

A secretion of the mollusc Cryptomphalus aspersa promotes proliferation, migration and survival of keratinocytes and dermal fibroblasts in vitro

Regenerative properties of skin decrease with age, and thus, the search for substances that minimize cutaneous ageing has increased in the last few years. The secretion of the mollusc Cryptomphalus Aspersa (SCA) is a natural product that bears regenerative properties when applied topically. The purpose of this work is to study the in vitro effects of SCA on cell proliferation and migration, as well as on cell-cell (E-cadherin and β-catenin) and cell-substrate (vinculin and β1-integrin) adhesion proteins expression, using a human keratinocyte cell line (HaCaT cells) and primary dermal fibroblasts (HF). We tested the effects of SCA on cell proliferation using a colorimetric assay. In addition, SCA-induced changes on cell migration were studied by wound-healing assays. Besides, Western blot and immunofluorescence microscopy were carried out to test the expression of different cell adhesion proteins. We found that SCA promotes proliferation and migration of HaCaT cells in a time- and dose-dependent manner. Moreover, treatment with SCA increases the migratory behaviour and the expression of adhesion molecules in both HaCaT and HF. Finally, SCA also improves cell survival and promotes phosphorylation of FAK and nuclear localization of β-catenin. These results shed light on the molecular mechanisms underlying the regenerative properties of SCA, based on its promoting effect on skin cell migration, proliferation and survival. Moreover, these results support future clinical uses of SCA in the regeneration of wounded tissues.

Diagnostic performance of malignant prostatic cells detection in blood for early detection of prostate cancer: comparison to prostatic biopsy

OBJECTIVES

Serum prostate specific antigen and digital rectal examination are the tests used as screening tests to detect prostate cancer. However, only approximately 30% of men with suspicion of cancer have it confirmed on prostate biopsy, and not all of these need treatment. Detection of circulating tumor cells in localized prostate cancer has given variable results, but it could be a useful complementary screening tool to detect prostate cancer in men with abnormal screening tests before the evaluation with prostate biopsy. To evaluate the diagnostic yield of the detection of mCPC as a complementary PC screening test in a population fulfilling criteria for a prostate biopsy for suspicion of PC.

METHODS

A prospective screening study of consecutive patients aged 45-80 years presenting to the urologist for PC screening. Inclusion criteria were PSA >4.0 ng/ml, PSA velocity >0.35 ng/ml/year and/or DRE suspicious for cancer. Patients fulfilling inclusion criteria had blood taken for mCPC detection and then underwent 12-core transrectal prostate biopsy. Double immune-histochemical staining with anti-PSA and anti-P504S was used to detect mCPC. Both cytologist and pathologist were blinded to the results of the biopsy, mCPC results and clinical details. The diagnostic yield of the presence or absence of mCPC was evaluated; the prostate biopsy was classified as cancer or no -cancer.

RESULTS

228 men participated, with a mean age of 66.8 ± 8.8 years and a median serum PSA of 5.15 ng/ml. 28.6% of the biopsies were positive for PC, and mCPC were detected in 31.0%of all cases. Sensibility, specificity and negative predictive value were 86.2%, 90.8% and 94.3% respectively. The negative and positive like-lihood ratios were 9.36 and 0.15. In men with a PSA <4.0ngml, 13.3% had cancer detected on biopsy, with a sensibility and specificity for mCPC detection of 83.3% and 84.6% and negative predictive value of 97.1%. All the mCPC determinations were interpretable. There were 9 false negative cases, all with small low grade tumors.

CONCLUSIONS

The use of mCPC detection could be useful as a complementary prostate cancer screening test, especially for excluding cancer, including patients with a serum PSA <4.0 ng/ml.

HIV infection, sexual risk behaviour and condom use in the Belize defense force

This study is the first Biological and Behavioral Surveillance Survey to be conducted among personnel in the Belize Defense Force. The purpose of the study was to understand the prevalence of HIV infection and risk behaviours, and to identify key correlates of sexual risk behaviours. A representative sample of personnel underwent serological testing and an Audio Computer-Assisted Self Interview. Of those sampled, 351 completed a blood test and 334 completed a behavioural interview. The prevalence of HIV was 1.14%. Twelve percent had ever reported being diagnosed with a sexually transmitted infection (STI) or screened positive for HIV infection. The odds of ever having an STI/HIV were higher among those who had less education, those who had sex with a commercial sex worker (CSW), those who ever engaged in receptive anal sex and those with post-traumatic stress disorder (PTSD). Alcohol abuse and PTSD were prevalent and associated with HIV risk behaviours. These results are being used to inform current prevention efforts.

Maturation of the neuromuscular junction in masseters of human fetus

OBJECTIVES

The aim of the present investigation is to examine if the histological maturation of the neuromuscular junction in the masseters of human fetuses has already begun by the 12-th week of gestation or not.

MATERIAL AND METHODS

Twenty-four masseter muscles from 14 human fetuses at gestational age 12 weeks were divided into two groups. In the first group, muscle sections were stained with Bielschowsky and Holzer stains for examination of neurofibrils and glial cells respectively. In the second group, rhodamine and fluorescein conjugated alpha-bungarotoxin were used to detect nicotinic receptors and anti-GAD for neuronal terminals.

RESULTS

It was observed the presence of one axon for each end-plate and glial cells spread over a branched axon. The nicotinic receptors clustered in the neuromuscular junction, neuronal terminals and large oval nucleus were detected.

CONCLUSIONS

These observations suggest that the maturation of the neuromuscular junctions of the masseter muscles in the human fetuses has already begun at the 12-th week of gestation.

The efficacy, tolerability, and speed of onset of fentanyl pectin nasal spray (FPNS) in the treatment of breakthrough cancer pain (BTCP): A multicenter, placebo-controlled, double-blind, two-phase crossover study

9535

Background: Breakthrough cancer pain (BTCP) affects up to 95% of patients with cancer pain but oral fentanyl formulations do not consistently match the typical time course of BTCP, which is rapid in onset and lasts for 30–60 min. To tailor fentanyl delivery for the treatment of BTCP, a new nasal formulation of fentanyl (fentanyl pectin nasal spray [FPNS]) has been developed to provide both rapid and controlled nasal delivery of fentanyl. Methods: A randomised, placebo-controlled, double-blind (DB) study assessing the efficacy and tolerability of FPNS was conducted in 114 cancer patients experiencing 1–4 BTCP episodes/day while taking ≥60 mg/day of oral morphine (or equivalent) for cancer pain. Patients who completed a titration phase (N=83) continued to a DB phase where 10 episodes of BTCP were treated with the effective dose identified during titration (7) or placebo (3). Pain intensity (PI) was measured using an 11-point categorical scale and pain relief (PR) using a 5-point scale, both PI and PR were measured at 5, 10, 15, 45 and 60 min post-dose. The primary endpoint was the Summed Pain Intensity Difference at 30 min (SPID30min). Secondary efficacy endpoints included Pain Intensity Difference (PID) from baseline, PI and PR. Safety was assessed by adverse events (AEs) and both objective and subjective nasal assessments. Results: Compared with placebo, FPNS significantly improved mean SPID30min scores (P<0.0001) and significantly improved SPID scores as early as 10 min (P<0.05) and up to 60 min (P<0.0001). Significant differences in favour of FPNS were found in PI as early as 5 min (P<0.05). Similar benefits were also seen with PID, with a trend at 5 min (P=0.07) that was significant from 10 min onward (P<0.01). PR was significant from 10 min (P<0.001) and at all time points to 60 min (P<0.001). Only 5.3% of patients withdrew from titration due to AEs; no significant nasal effects were reported. Conclusions: FPNS provided rapid and effective analgesia in BTCP and was generally safe and well tolerated.

[Table: see text]

Open label, prospective, randomized controlled trial of an endoscopic duodenal-jejunal bypass sleeve versus low calorie diet for pre-operative weight loss in bariatric surgery

BACKGROUND

The duodenal-jejunal bypass sleeve (DJBS) has been shown to achieve a completely endoscopic duodenal exclusion without the need for stapling. This report is the first randomized controlled trial for weight loss.

METHODS

In a 12-week, prospective, randomized study, subjects received either a low fat diet and the DJBS or a low fat diet control (no device). Twenty-five patients were implanted with the device and 14 received the control. The groups were demographically similar. Both groups received counseling at baseline only, which consisted of a low calorie diet, and exercise/behavior modification advice. No additional counseling occurred in either group. Measurements included starting and monthly body weight and serum blood tests. The device group also had a plain abdominal film post implant, a monthly KUB and a 4-week post explant EGD.

RESULTS

Twenty device (80%) subjects maintained the DJBS without a significant adverse event for the 12-week duration. At 12 weeks, the mean excess weight loss was 22% and 5% for the device and control groups, respectively (p < 0.001). Five subjects (20%) were endoscopically explanted early secondary to upper GI (UGI) bleeding (n = 3), anchor migration (n = 1) and sleeve obstruction (n = 1). The UGI bleeding occurred at a mean of 13.8 days post implant. EGD was performed in each of these cases with no distinct bleeding source identified. No blood transfusion was required. The migration occurred on day 47 and manifested as abdominal pain. The subject with the sleeve obstruction presented with abdominal pain and vomiting on day 30. Eight subjects (40%) underwent the 4 week post explant EGD at which time mild degrees of residual duodenal inflammation was noted.

CONCLUSION

The DJBS achieves noninvasive duodenal exclusion and short term weight loss efficacy. Longer term randomized controlled sham trials for weight loss and treatment of T2DM are underway.

High prevalence of infections in patients with systemic lupus erythematosus and pulmonary haemorrhage

The main objective of this study is to describe the presence of infections in patients with pulmonary haemorrhage and systemic lupus erythematosus. Patients with systemic lupus erythematosus and pulmonary haemorrhage were thoroughly evaluated in the first 48 hours with imaging plus bronchoscopy and bronchoalveolar fluid analysis. If needed, videoassisted thoracoscopy and lung biopsy were performed too. In all, search for bacterial, mycobacterial and fungal infections proceeded. Appropriate blood, bronchoalveolar fluid and tissue cultures were taken. Patients were treated with antibiotics and corticosteroids in case of infection. Otherwise, they received initial intravenous methylprednsiolone pulses for 3 days as standard therapy for pulmonary haemorrhage in systemic lupus erythematosus. Additional treatment with immunosuppressives was further decided by the treating physicians. Fourteen events in 13 patients were evaluated. In eight events (57%), an infection was demonstrated. Aetiological agents included Pseudomonas sp. and Aspergillus fumigatus. Four patients died, three of them because of the pulmonary infection and one because of cerebral haemorrhage secondary to severe systemic hypertension, 48 hours after methylprednisolone treatment. Patients with systemic lupus erythematosus and pulmonary haemorrhage have a high prevalence of infections. The influence of pulmonary haemorrhage in the setting of systemic lupus erythematosus needs further study to establish adequate treatment and to reduce the high mortality of this complication.

[Clinical nutrition knowledge in health care members of University Hospitals of Paraguay]

BACKGROUND

Adequate clinical nutrition care is an integral part of the complete treatment of hospitalised patients, requiring specific knowledge from the health care team. The aim of this study is to assess, in Paraguay, the health care team ability in clinical care nutrition.

MATERIALS AND METHODS

A survey was made including 174 people of Paraguay university hospitals (29% physicians, 29% medicine graduating students, 11% pharmaceutics, 24% nurses, 7% dieticians), by answering voluntarily a multiple choice questionnaire of 20 items.

RESULTS

The median score of the 20 questions was 6 (0-15). Physicians obtained a median of 6 (2-15), graduating students 7 (2-14), pharmaceutics 7 (0-15), nurses 3 (0-11), and dieticians 9 (4-13). The dieticians obtained a significantly higher score than the other groups (p < 0.005).

CONCLUSIONS

The knowledge about clinical nutrition in the health care members from university hospitals is not adequate. The level of education in clinical nutrition is better in the dietician.

A heterozygous mutation in the desert hedgehog gene in patients with mixed gonadal dysgenesis

Aetiology of mixed gonadal dysgenesis (MGD) has not been completely elucidated. Molecular analyses have failed to demonstrate the presence of mutations in sex-determining region on Y chromosome (SRY); it has been suggested that these individuals may bear mutations in other genes involved in the testis-determining pathway. Desert hedgehog's (DHH) importance regarding male sex differentiation has been demonstrated in various studies we describe here, for the first time, two cases of MGD in which a monoallelic single base deletion in DHH is associated with the disorder. Genomic DNA was isolated from paraffin-embedded gonad tissue from 10 unrelated patients with MGD and three controls; in addition to, DNA from peripheral blood leukocytes in 100 controls. Coding sequence abnormalities in DHH were assessed by exon-specific PCR, single-stranded conformation polymorphism (SSCP) and direct sequencing. In two patients, a heterozygous 1086delG in exon 3 was found. Comparing previously described mutations in DHH to the one observed in this study, we can affirm that the phenotypic spectrum of patients with gonadal dysgenesis due to mutations in DHH is variable. This study continues to demonstrate the importance that DHH has in mammalian male sexual differentiation, providing extended evidence that DHH constitutes a key gene in gonadal differentiation.

Different Proinflammatory Cytokine Serum Pattern in Neonate Patients Undergoing Open Heart Surgery. Relevance of IL-8

The purpose of this work was to investigate the clinical significance of serum levels of proinflammatory cytokines in pediatric patients undergoing cardiopulmonary bypass. We divided the patients in two groups: 8 neonates, and 19 non-newborn children. IL-1beta, IL-6, IL-8, and TNF serum levels were quantified before sternotomy, at admission to the PICU (30 min postoperatively), 24 h after the onset of surgery and 3 days after the operation. Surgical cardiac stress elicits significant increments of IL-6, IL-8 and TNF serum concentrations in both neonates and non-neonates, regardless of their preoperative clinical condition. However, in newborns the magnitude of the proinflammatory cytokine increments was, in particular with IL-8, remarkably greater than in older children. Moreover, neonate and non-neonate patients showed clearly disparate patterns of serum concentrations over time of both IL-8 and TNF. There was a marked relationship between IL-8 levels and postoperative morbidity, evaluated by pulmonary dysfunction, days on inotropic support and days of PICU stay in both neonates and non-neonates patients. In contrast, we found no relationship between serum levels of IL-6 and TNF and postoperative clinical data. Newborn and non-newborn patients undergoing cardiopulmonary bypass exhibit dissimilar patterns of proinflammatory cytokines. IL-8 might be implicated in the multiorganic dysfunction related to cardiopulmonary bypass in pediatric patients.

Pulmonary injuries and cytokine levels after the intraperitoneal administration of pancreatic homogenates in rats

INTRODUCTION

Our objective was to investigate the effects of the administration of pancreatic homogenates, with or without enzymatic activation, to healthy animals regarding cytokine serum levels and the development of pulmonary distress.

MATERIAL AND METHODS

106 male Wistar rats, divided into three groups, were studied: group A, intraperitoneal administration of homogenates activated with enterokinase; group B, homogenates without enterokinase; and group C, control group with administration of physiological saline solution. Each group was divided into 4 subgroups according to the time of sacrifice: 0, 2, 6 and 24 hours. We studied the pulmonary and pancreatic histology, serum parameters of renal and hepatic function, and serum levels of IL-1beta, IL-6 and TNFalpha.

RESULTS

There was no mortality in any group. Pancreatic disorders in A and B groups were noted at 24 hours. These two groups had statistically significant higher transaminase serum levels than those of the control group, as well as statistically significant higher creatinine levels in group A. IL-1beta showed a statistically significant higher level at 6 h in both groups, A and B, but was higher in group A, which also exhibited significant pulmonary histologic damage with respect to controls at 6 h.

CONCLUSIONS

The higher IL-1beta level in group A may result from production by peritoneal macrophages under the influence of homogenate enzymatic activation. This may be the reason for lung damage.

Mutations in the desert hedgehog (DHH) gene in patients with 46,XY complete pure gonadal dysgenesis

Mutations of SRY are the cause of complete pure gonadal dysgenesis (PGD) in 10-15% of patients. In the remaining individuals, it has been suggested that mutations in other genes involved in the testis-determining pathway could be causative. We describe the first report in which three cases of 46,XY complete PGD are attributed to mutations of the Desert hedgehog (DHH) gene. DHH was sequenced using genomic DNA from paraffin-embedded gonadal tissue from six patients with complete 46,XY PGD. Mutations were found in three patients: a homozygous mutation in exon 2, responsible for a L162P, and a homozygous 1086delG in exon 3. Mutated individuals displayed 46,XY complete PGD, differentiating from the only previously described patient with a homozygous DHH mutation, who exhibited a partial form of PGD with polyneuropathy, suggesting that localization of mutations influence phenotypic expression. This constitutes the first report where mutations of DHH are associated with the presence of 46,XY complete PGD, demonstrating that the genetic origin of this entity is heterogeneous and that disorders in other genes, different from SRY, involved in the testis-determining pathway are implicated in abnormal testicular differentiation in humans. These data extend previous reports demonstrating DHH is a key gene in gonadal differentiation.