Characterization and long-term follow-up of children with brugada syndrome: experience from a tertiary paediatric referral centre

Introduction

Brugada syndrome (BrS) is an autosomal dominant channelopathy, which typically presents in young adults. It can also be diagnosed in children, but data in this age group is scarce.

Purpose

To describe the clinical features, management and long-term follow-up of children with BrS history followed-up in a tertiary paediatric referral centre.

Methods

Single centre retrospective study of consecutive patients with history of BrS, defined as having a BrS positive phenotype (BrS(+)), or a negative phenotype-positive genotype (BrS(−)). They were all followed up in a paediatric heart rhythm clinic. Clinical and demographical data were collected and analysed according to the phenotype.

Results

30 patients were included, with a median age at diagnosis of 7 years (IQR 1–13) and a mean follow-up time of 7±3 years. Sixteen patients were BrS(+), predominantly male (n=13, 81%). 88% (n=14) performed a genetic test, which was positive in 57% (n=8); the most frequent mutation was SCN5A (n=5). Family history of BrS was present in 56% (n=9) and almost one third had family history of sudden cardiac death (SCD). Most of the patients had a type 1 Brugada ECG pattern (n=14) and 2 patients presented a fever and drug induced pattern, respectively. Fourteen patients were BrS(−), mostly female (n=11, 79%) with a loss-of-function mutation in the SCN5A gene (n=10). They all had family members with BrS, mainly from the paternal side, and 43% (n=6) mentioned SCD history. Although most of the patients were asymptomatic, the prevalence of rhythm or conduction disturbances was not infrequent, particularly in BrS(+) patients (n=12, 75%). Also, in this group and during follow-up, 3 patients had documented supraventricular tachyarrhythmias, and 2 patients had syncope episodes, one of which required an implantable cardioverter-defibrillator. No events were reported in the BrS(−) patients. Nine patients (n=9/30, 30%) were hospitalized, 3 due to an arrhythmic event (all in the BrS(+) group). Overall, no sudden cardiac death event was reported during follow-up.

Conclusion

In our study, although the majority of the patients were asymptomatic, the occurrence of arrhythmic events was not negligible, especially in the BrS(+) patients. Despite the significant family history, patients with BrS(−) had no events reported during follow-up. Nevertheless, the management of these patients is not clear cut, and a personalized therapeutic strategy with close follow-up is essential.

Funding Acknowledgement

Type of funding sources: None.

An outbreak of infective endocarditis during the COVID-19 pandemic? - an observational retrospective single centre study

Funding Acknowledgements

Type of funding sources: None.

Infective endocarditis (IE) is described as an uncommon and challenging infective disease, due to its presentation variability. Its mortality remains high besides the better disease knowledge and therapeutic progress.

The aim of this study was to describe the clinical features and the incidence of IE. Furthermore, we try to identify the risk factors associated with early mortality.

A retrospective study was conducted and all patients diagnosed with definite or possible IE between January 2015 and June 2020, according to the modified Duke criteria, were included. Patient selection and information collection were obtained through medical records. Outcomes were in-hospital and 3 months after discharge mortality.

Group comparisons and multivariate logistic regression analysis were performed. A p-value less than 0.05 is statistically significant.

We analysed 51 patients, which 41 were admitted between 2015 and 2019 with a mean incidence of 8.2 cases per year. In 2020, 10 cases were diagnosed, corresponding to a percentual increase of 143.9%.

Of the 51 patients, 70.6% were male. The mean age was 65 years. Fever was the main presentation feature at admission. We counted 33.3% prosthetic valve endocarditis (PVE) and 5.9% IE device-related. The most common pathogens were Streptococcus gallolyticus (13.7%) and Streptococcus oralis (13.7%). 35 patients (68.6%) had local complications and 26 patients (51%) had systemic complications. One-third of the patients was referenced to surgical treatment. Overall in-hospital mortality was 19.6% and early mortality at 3 months was 27.5%.

In the univariate analysis, early mortality was higher in diabetes mellitus (DM) patients (p < 0.01) and in those who developed sepsis during hospitalization (p = 0.04). In multivariate logistic regression, only DM (OR = 15.8, 95% CI [3.2, 79.0]) was shown to be an independent factor of mortality.

The incidence of IE increased during the first semester of 2020, possibly due to the increased attention given to patients with fever. Diabetes mellitus was found to be the only independent predictor of mortality. More national multicentre studies are needed.

Eating disorder examination-questionnaire – 7: Construct validity in a sample of portuguese overweight women

Introduction

Although the Eating Disorder Examination Questionnaire (EDEQ; Fairburn et al. 2008) is the most used instrument worldwide for the assessment of eating disorders symptoms, its factorial structure considerably varies, which limits its construct validity. Using exploratory factor analisys in data from a sample of overweight women, our group found a three-factors structure of the EDEQ Portuguese version (Peixoto et al. 2013), Although it was in accordance with other psychometric studies (eg. Peterson et al 2007), it was different from the original matrix. Further investigation regarding its factor structure has been conducted, with studies supporting a modified seven-item-three-factors structure (dietary restraint, shape/weight overvaluation, body dissatisfaction) with improved psychometric properties (Grilo et al. 2013, 2015), including with Portuguese samples (Machado et al. 2018; Santos et al. 2019).

Objectives

To analyze if the EDEQ version composed of seven items and three factors is replicated in a Portuguese sample of overweight women.

Methods

The EDEQ was administered to an outpatient sample of 276 women (Mean age= 43.85±11.89 years; Mean BMI=32.82±5.43 Kg/height²) attending a weight loss treatment consultation in a public hospital.

Results

Confirmatory factor analysis (CFA) revealed an adequate fit of the EDEQ-7 second order model with three dimensions (χ²/df=1.5497; RMSEA=.0452, CFI=.9955, TLI=.9914, GFI=.xxx; p<.001). The EDEQ7 Cronbach’s alphas for the total and its dimensions were α<.70.

Conclusions

Given its good psychometric properties, the overlap of the measurement model with those found with different samples and the reduced number of items, the EDEQ7 will be very useful both in research and clinical settings with/for overweight women.

Quantification and mapping of urban fluxes under climate change: Application of WRF-SUEWS model to Greater Porto area (Portugal)

Climate change and the growth of urban populations are two of the main challenges facing Europe today. These issues are linked as climate change results in serious challenges for cities. Recent attention has focused on how urban surface-atmosphere exchanges of heat and water will be affected by climate change and the implications for urban planning and sustainability. In this study energy fluxes for Greater Porto area, Portugal, were estimated and the influence of the projected climate change evaluated. To accomplish this, the Weather Research and Forecasting Model (WRF) and the Surface Urban Energy and Water Balance Scheme (SUEWS) were applied for two climatological scenarios: a present (or reference, 1986-2005) scenario and a future scenario (2046-2065), in this case the Representative Concentration Pathway RCP8.5, which reflects the worst set of expectations (with the most onerous impacts). The results show that for the future climate conditions, the incoming shortwave radiation will increase by around 10%, the sensible heat flux around 40% and the net storage heat flux around 35%. In contrast, the latent heat flux will decrease about 20%. The changes in the magnitude of the different fluxes result in an increase of the net all-wave radiation by 15%. The implications of the changes of the energy balance on the meteorological variables are discussed, particularly in terms of temperature and precipitation.

Raising standards in clinical research - The impact of the ECRIN data centre certification programme, 2011-2016

The nature and the purpose of the ECRIN Data Centre Certification Programme are summarised, and a very brief description is given of the underlying standards (129 in total, divided into 19 separate lists). The certification activity performed so far is described. In a pilot phase 2 centres were certified in 2012. Calls in 2014 and 2015 resulted in a further 8 certified centres, with 2 certifications still in progress, and the 2016 call has generated several additional applications. The impact and benefits of the programme are listed, divided into a) the effects of the introduction of the standards, b) the effects of the certification programme in general, and c) the effects of the certification programme on individual units. The discussion emphasises the generally positive impact of the programme so far but stresses the need to better clarify the perspective and role of the programme.

Influence of urban resilience measures in the magnitude and behaviour of energy fluxes in the city of Porto (Portugal) under a climate change scenario

Different urban resilience measures, such as the increase of urban green areas and the application of white roofs, were evaluated with the WRF-SUEWS modelling system. The case study consists of five heat waves occurring in Porto (Portugal) urban area in a future climate scenario. Meteorological forcing and boundary data were downscaled for Porto urban area from the CMIP5 earth system model MPI-ESM, for the Representative Concentration Pathway RCP8.5 scenario. The influence of different resilience measures on the energy balance components was quantified and compared between each other. Results show that the inclusion of green urban areas increases the evaporation and the availability of surface moisture, redirecting the energy to the form of latent heat flux (maximum increase of +200Wm(-2)) rather than to sensible heat. The application of white roofs increases the solar radiation reflection, due to the higher albedo of such surfaces, reducing both sensible and storage heat flux (maximum reductions of -62.8 and -35Wm(-2), respectively). The conjugations of the individual benefits related to each resilience measure shows that this measure is the most effective one in terms of improving the thermal comfort of the urban population, particularly due to the reduction of both sensible and storage heat flux. The obtained results contribute to the knowledge of the surface-atmosphere exchanges and can be of great importance for stakeholders and decision-makers.

Effects of detraining on neuromuscular performance in a selected group of elite women pole-vaulters: a case study

AIM

to determine the effects of 28 days of inactivity on neuromuscular performance of elite women pole-vaulters.

METHODS

Four athletes undertook measurements of rate of force development (RFD), unloaded and loaded vertical jump tests, drop jumps and a 45 m sprint test before and after a transition period of planned inactivity.

RESULTS

The RFD and the ability to accelerate over very short distances (5 m) while sprinting improved after training cessation. Acceleration over longer distances (5-45 m) was impaired, while unloaded and loaded vertical jump tests suffered trivial to small changes.

CONCLUSIONS

Therefore, we conclude that detraining periods of approximately one month or even longer may be implemented in elite pole-vaulters without significantly impairing performance. In addition, given that some neuromechanical capacities are enhanced after training reduction, our results can help coaches to implement tapering strategies in order to induce neuromuscular improvements and/or to achieve peak performance.

Three dimensional anatomy of the human nucleus accumbens

BACKGROUND

The Nucleus accumbens (Acc) is the main structure of the ventral striatum. It acts as a motor-limbic interface, being involved in emotional and psychomotor functions, frequently disturbed in neuropsychiatric disorders such as obsessive compulsive disorder and addiction. Most of the studies concerning the Acc were made in animals and those performed in humans are contradictory. Nevertheless, it has become a target for stereotactic deep brain stimulation for some of those diseases, when refractory to medical treatment. Previous studies performed by our group have established the localization, limits and dimensions of the human Acc and its stereotactic coordinates. Now it is our purpose to perform the Acc anatomical three-dimensional (3D) reconstruction in order to clarify its shape and topography and to render this nucleus a safer target for stereotactic procedures.

METHODS

Anatomical coronal slicing of ten Acc from human brains was performed, perpendicular to the anterior commissure-posterior commissure line and to the midline; then the Acc contours were traced and its dimensions and 3D stereotactic coordinates measured, on each slice. Finally a 3D computerized model was created.

RESULTS

The human Acc was identified as a distinct brain structure, with clear-cut limits on its posterior half. It lies parallel to the midline, descends caudally, and progresses from a globose to a flattened and dorsolateral concave shape. Its main expression is subcomissural.

CONCLUSION

This study defined more accurately the 3D anatomy of the human Acc, providing new tools for stereotactic procedures.

Lead availability in soils from Portugal's Centre Region with special reference to bioaccessibility

Previous environmental biomonitoring studies indicated higher environmental lead (Pb) pollution levels at the districts of Aveiro and Leiria (Portugal). In evaluating the risk for human health, which is associated with contaminated soils after oral uptake, total soil concentrations have generally been held against criteria established from toxicological studies based upon the assumption that the uptake of the contaminant is similar in the toxicological studies and from the soils assessed. This assumption is not always valid, as most toxicological studies are carried out with soluble forms of the contaminants, whereas many soil contaminants are or become embedded in the soil matrix and thus exhibit limited availability. This study intends to estimate the soluble fraction of Pb in the soils from central Portugal, and to assess the bioaccessibility of Pb and, hence, infer exposure and risk for human health. Yet, as the physical-chemical properties of the soil exert some control over the solubility of Pb in the surface environment, the relation between such soil properties and the estimated soluble and/or bioaccessible fractions of Pb is also investigated. Other objective, with a more practical nature, was to give some contribution to find a suitable in vitro mimetic of the gastrointestinal tract environment. The results indicate relatively low total metal concentrations in the soils, even if differences between regions were observed. The Aveiro district has the higher total Pb concentration and the metal is in more soluble forms, that is, geoavailable. Soils with higher concentrations of soluble Pb show higher estimates of bioaccessible Pb. Soil pH seems to influence human bioaccessibility of Pb.

Development of a European system for identification of emerging mycotoxins in wheat supply chains

This paper describes the results of a research project aimed at the conceptual development of an identification system for emerging mycotoxins in European feed and food supply chains of wheat. Basic requirements for such a system were addressed, including the selection of indicators, locating information sources, development of underlying model, and investigation of stakeholders' needs. The selection and ranking of key indicators for identifying emerging mycotoxins was based on a literature review, followed by a structured expert judgment study. The expert study was based on the Delphi technique and used a panel of 43 European experts. The Delphi procedure resulted in a selected set of 12 key indicators for each of three relevant stages of the wheat chain (cultivation; transport and storage; processing). For wheat cultivation, these were: relative humidity/rainfall, crop rotation, temperature, tillage practice, water activity in the kernels, crop variety, harvest conditions, changes in fungal populations, fungicide use, plant health, regional infection pressure and food safety awareness. For the majority of the selected indicators, information sources were identified in specific European countries. However, most sources are not readily accessible and particular data is lacking. A theoretical concept for a model underlying the envisioned emerging mycotoxin identification system has been developed. The model links the key indicators and their information sources to aid and promote identification of emerging mycotoxins. It manages different types of information sources and levels of available information. The needs of various stakeholder groups regarding the system were investigated by means of two empirical elicitation sessions. The results showed that all stakeholders considered that such a system would be beneficial. One major challenge expected in establishing the system is stakeholder commitment to sharing data and information. This requires great efforts in improving communication and interaction between the key stakeholders.

Vanadium and cadmium in vivo effects in teleost cardiac muscle: metal accumulation and oxidative stress markers

Several biological studies associate vanadium and cadmium with the production of reactive oxygen species (ROS), leading to lipid peroxidation and antioxidant enzymes alterations. The present study aims to analyse and compare the oxidative stress responses induced by an acute intravenous exposure (1 and 7 days) to a sub-lethal concentration (5 mM) of two vanadium solutions, containing different vanadate n-oligomers (n=1-5 or n=10), and a cadmium solution on the cardiac muscle of the marine teleost Halobatrachus didactylus (Lusitanian toadfish). It was observed that vanadium is mainly accumulated in mitochondria (1.33+/-0.26 microM), primarily when this element was administrated as decameric vanadate, than when administrated as metavanadate (432+/-294 nM), while the highest content of cadmium was found in cytosol (365+/-231 nM). Indeed, decavanadate solution promotes stronger increases in mitochondrial antioxidant enzymes activities (catalase: +120%; superoxide dismutase: +140%) than metavanadate solution. On contrary, cadmium increases cytosolic catalase (+111%) and glutathione peroxidases (+50%) activities. It is also observed that vanadate oligomers induce in vitro prooxidant effects in toadfish heart, with stronger effects induced by metavanadate solution. In summary, vanadate and cadmium are differently accumulated in blood and cardiac subcellular fractions and induced different responses in enzymatic antioxidant defence mechanisms. In the present study, it is described for the first time the effects of equal doses of two different metals intravenously injected in the same fish species and upon the same exposure period allowing to understand the mechanisms of vanadate and cadmium toxicity in fish cardiac muscle.

Vanadium distribution, lipid peroxidation and oxidative stress markers upon decavanadate in vivo administration

The contribution of decameric vanadate species to vanadate toxic effects in cardiac muscle was studied following an intravenous administration of a decavanadate solution (1mM total vanadium) in Sparus aurata. Although decameric vanadate is unstable in the assay medium, it decomposes with a half-life time of 16 allowing studying its effects not only in vitro but also in vivo. After 1, 6 and 12h upon decavanadate administration the increase of vanadium in blood plasma, red blood cells and in cardiac mitochondria and cytosol is not affected in comparison to the administration of a metavanadate solution containing labile oxovanadates. Cardiac tissue lipid peroxidation increases up to 20%, 1, 6 and 12h after metavanadate administration, whilst for decavanadate no effects were observed except 1h after treatment (+20%). Metavanadate administration clearly differs from decavanadate by enhancing, 12h after exposure, mitochondrial superoxide dismutase (SOD) activity (+115%) and not affecting catalase (CAT) activity whereas decavanadate increases SOD activity by 20% and decreases (-55%) mitochondrial CAT activity. At early times of exposure, 1 and 6h, the only effect observed upon decavanadate administration was the increase by 20% of SOD activity. In conclusion, decavanadate has a different response pattern of lipid peroxidation and oxidative stress markers, in spite of the same vanadium distribution in cardiac cells observed after decavanadate and metavanadate administration. It is suggested that once formed decameric vanadate species has a different reactivity than vanadate, thus, pointing out that the differential contribution of vanadium oligomers should be taken into account to rationalize in vivo vanadate toxicity.

Vanadium distribution following decavanadate administration

An acute exposure of two vanadate solutions-metavanadate and decavanadate-containing different vanadate oligomers, induces different patterns of subcellular vanadium distribution in blood plasma, red blood cells (RBC), and cardiac muscle subcellular fractions of the fish Sparus aurata (gilthead seabream). The highest amount of vanadium was found in blood plasma 1 h after (5 mM) intravenous vanadate administration (295 +/- 64 and 383 +/- 104 microg V/g dry tissue, for metavanadate and decavanadate solutions, respectively), being 80-fold higher than in RBC. After 12 h of administration, the amount of vanadium in plasma, as well as in cardiac cytosol, decreased about 50%, for both vanadate solutions. During the period between 1 and 12 h, the ratio of vanadium in plasma/vanadium in RBC increased from 27 to 128 for metavanadate, whereas it remains constant (77) for decavanadate. Both vanadium solutions were primarily accumulated in the mitochondrial fraction (138 +/- 0 and 195 +/- 34 ng V/g dry tissue for metavanadate and decavanadate solutions, respectively, after 12 h exposure), rather than in cytosol. The amount of vanadium in cardiac mitochondria was twofold higher than in cytosol, earlier for metavanadate (6 h) than for decavanadate (12 h). It is concluded that, in fish cardiac muscle, the vanadium distribution is dependent on the administration of decameric vanadate, with vanadium being mainly distributed in plasma, before being accumulated into the mitochondrial fraction.

Vanadate oligomers: in vivo effects in hepatic vanadium accumulation and stress markers

The formation of vanadate oligomeric species is often disregarded in studies on vanadate effects in biological systems, particularly in vivo, even though they may interact with high affinity with many proteins. We report the effects in fish hepatic tissue of an acute intravenous exposure (12, 24 h and 7 days) to two vanadium(V) solutions, metavanadate and decavanadate, containing different vanadate oligomers administered at sub-lethal concentration (5 mM; 1 mg/kg). Decavanadate solution promotes a 5-fold increase (0.135 +/- 0.053 microg V(-1) dry tissues) in the vanadium content of the mitochondrial fraction 7 days after exposition, whereas no effects were observed after metavanadate solution administration. Reduced glutathione (GSH) levels did not change and the overall reactive oxygen species (ROS) production was decreased by 30% 24 h after decavanadate administration, while for metavanadate, GSH levels increased 35%, the overall ROS production was depressed by 40% and mitochondrial superoxide anion production decreased 45%. Decavanadate intoxication did not induce changes in the rate of lipid peroxidation till 12 h, but later increased 80%, which is similar to the increase observed for metavanadate after 24 h. Decameric vanadate administration clearly induces different effects than the other vanadate oligomeric species, pointing out the importance of taking into account the different vanadate oligomers in the evaluation of vanadium(V) effects in biological systems.

Oxidative stress in toadfish (Halobactrachus didactylus) cardiac muscle. Acute exposure to vanadate oligomers

Vanadate solutions as "metavanadate" (containing ortho and metavanadate species) and "decavanadate" (containing mainly decameric species) (5 mM; 1 mg/kg) were injected intraperitoneously in Halobatrachus didactylus (toadfish), in order to evaluate the contribution of decameric vanadate species to vanadium (V) intoxication on the cardiac tissue. Following short-term exposure (1 and 7 days), different changes on antioxidant enzyme activities-superoxide dismutase (SOD), catalase (CAT), selenium-glutathione peroxidase (Se-GPx), total glutathione peroxidase (GPx), lipid peroxidation and subcellular vanadium distribution were observed in mitochondrial and cytosolic fractions of heart ventricle toadfish. After 1 day of vanadium intoxication, SOD, CAT and Se-GPx activities were decreased up to 25%, by both vanadate solutions, except mitochondrial CAT activity that increased (+23%) upon decavanadate administration. After 7 days of exposure, decavanadate versus metavanadate solutions promoted different effects mainly on cytosolic CAT activity (-56% versus -5%), mitochondrial CAT activity (-10% versus +10%) and total GPx activity (+1% versus -35%), whereas lipid peroxidation products were significantly increased (+82%) upon 500 microM decavanadate intoxication. Accumulation of vanadium in total (0.137+/-0.011 microg/g) and mitochondrial (0.022+/-0.001 microg/g) fractions was observed upon 7 days of metavanadate exposure, whereas for decavanadate, the concentration of vanadium increased in cytosolic (0.020+/-0.005 microg/g) and mitochondrial (0.021+/-0.009 microg/g) fractions. It is concluded that decameric vanadate species are responsible for a strong increase on lipid peroxidation and a decrease in cytosolic catalase activity thus contributing to oxidative stress responses upon vanadate intoxication, in the toadfish heart.

Enkephalin-processing oligopeptidases in cobra venom: inhibition by thiorphan and bestatin reveals co-operative actions

The peptidase inhibitors thiorphan and bestatin were tested for their ability to inhibit the actions of the oligopeptidases contained in the venom of the Taiwan cobra (Naja naja atra). With methionine enkephalin (TyrGlyGlyPheMet) as substrate, thiorphan was an effective inhibitor of cleavage of the GlyPhe peptide bond while bestatin inhibited cleavage of the TyrGly peptide bond. Thiorphan and bestatin also inhibited subsequent cleavage of the fragments GlyGlyPheMet and TyrGlyGly respectively. These inhibitors reveal an interplay between the venom oligopeptidases in which the enzymes provide additional substrates for each other following their initial competitive attack on the neuropeptide. A possible explanation is that the system is intended to ensure a steady release of Tyr, GlyGly and PheMet over time. Significantly, Tyr is the favoured substrate of the L-amino acid oxidase present in the venom, which rapidly transforms this aromatic amino acid into phenolic derivatives. The efficacies of these inhibitors also suggest that there are similarities between the venom oligopeptidases and the peptidases associated with the processing of enkephalin in its normal contexts.

Mutation frequency and spectrum in lymphocytes of small cell lung cancer patients receiving etoposide chemotherapy

Etoposide, a topoisomerase II inhibitor, is a chemotherapeutic agent that is used in the treatment of a wide variety of neoplasms, including small cell lung cancer, germ cell cancer, testicular cancer, acute leukemia, and lymphoma. Although it has proven valuable, etoposide is also a known mutagen and has been implicated as a causative agent of treatment-related secondary acute nonlymphocytic leukemia. We have investigated the induction of mutation following etoposide treatment in vivo using the hypoxanthine phosphoribosyltransferase (hprt) T-cell cloning assay in small cell lung cancer patients receiving single-drug etoposide chemotherapy. This report presents results on the monitoring of 12 patients (mean age, 74.8 +/- 6.0 years; range, 66-83 years) before, during, and after chemotherapy. The treatment regimen included up to six cycles of oral etoposide given in twice-daily 50-mg tablets for 10-14 days, separated by 2 weeks of rest. Peripheral blood samples were collected on the first day of each cycle prior to treatment. Patients received one to six etoposide cycles and were followed for 0.7-5.3 months after the start of chemotherapy (total etoposide dose, 1.4-8.4 g). Results from the pooled data show no significant increase in the hprt mutant frequency (pretreatment, 46 x 10(-6) +/- 38 x 10(-6), versus posttreatment, 55 x 10(-6) +/- 46 x 10(-6)), although considerable interpatient variability was observed. Of a total of 424 selected mutants, 228 were analyzed by sequencing hprt cDNA. Spectra of 56 pretreatment and 147 posttreatment mutations revealed significant enhancement of AT-->TA transversions and a concomitant decrease in the number of GC-->TA transversions in posttreatment spectra, when they were compared with pretreatment or control spectra. No evidence for the induction of gross deletions or rearrangements was found in the spectra of mutants that were recovered from patients after etoposide treatment. The lack of enhanced mutant frequency after treatment suggests that the etoposide chemotherapy was not particularly effective in inducing mutation, as measured by the hprt assay. It is proposed that mutated cells are eliminated through apoptosis due to accumulated DNA damage.

[Evaluation of the protection received by a BC antimeningococcal vaccine in the State of Santa Catarina, Brazil, 1990/92]

Results of the evaluation of the anti-meningococcal BC Cuban vaccine based on routine epidemiological surveillance information of meningitis for the years 1990 to 1992, following mass-vaccination of 232,022 children aged between 3 months and 7 years in 1989/90 during an epidemic of serogroup B meningococcal disease in the State of Santa Catarina, Brazil, are presented. The protective efficacy of the vaccine was calculated from the incidence rates for the cohort of vaccinated and non-vaccinated children in 20 municipalities. Main results for cases confirmed by bacteriological tests were 59% (CI 95%: 23 to 78%) for children aged under 4 years and 78% (CI 95%: 54 to 90%) for children aged 4 to 7 years. Eighty-six percent of cases serogrouped (n = 29) were B, and in these cases efficacy increased to 66% (< 4 years) and 88% (4-7 years), but at 95% CI were wider. The protective efficacy based on death rates from the disease in children < 4 years was 76% (CI 95%: 41 to 91%). There was no evidence of decreasing protective efficacy in the three year follow-up, as shown by the yearly estimates. An interesting hypothesis arising from the findings is that the lower protective efficacy for children aged < 4 years, observed in studies in which only cases confirmed by laboratory tests are analysed, could be due to a selective effect of this procedure. More severe cases die shortly after the onset of the disease, often before medical care is provided. On the other hand, the attenuation of the disease by vaccination gives a better chance for medical intervention and collection of samples for laboratory analysis. Finally, the authors support the use of the vaccine in epidemics of serogroup B meningococcal disease. They also suggest that three, rather than two doses of vaccine should be tested in children under 2 years of age to further increase its efficacy.

Risk factors for left ventricular hypertrophy: role of Na(+)-Li+ countertransport

Left ventricular hypertrophy (LVH) is associated with an increase in cardiovascular death in essential hypertension (EH). The factors involved in LVH are multiple and complex. We looked for risk factors of LVH in a group of 28 nonobese patients with EH (mean age = 45.3 years). We analyzed the activity of several erythrocyte ion transports (Vmax of NaLi countertransport, NaKCl cotransport and NaK-pump, and the Na-leak Kp Na), the intracellular Na and the insulin sensitivity index. All these parameters were used as independent variables whereas the left ventricular mass index (LVMI) was used as the dependent variable. Variables showing a significant univariate correlation (age, time of EH, mean blood pressure and Vmax of NaLi countertransport) were introduced in a stepwise multiple regression model. Only age (P = 0.014), time of EH (P = 0.038) and Vmax of NaLi countertransport (P = 0.032) were independently associated with LVMI (R2 = 0.581, P = 0.0001). The NaLi CT, an operating mode of the NaH exchanger that facilitates cellular growth, may be a marker of LVH, and consequently a marker of increased cardiovascular risk.

Oral etoposide and carboplatin. Effective therapy for elderly patients with small cell lung cancer

PURPOSE

Elderly patients with small cell lung cancer (SCLC) and/or those with comorbid conditions are frequently not considered candidates for standard combination chemotherapy. An active, but less toxic regimen is needed for this group of patients.

PATIENTS AND METHODS

Forty-seven elderly (> 65 years) or medically unfit patients with SCLC were treated with oral etoposide 100 mg/m2 x 7 days and carboplatin 150 mg/m2 day 1. Treatment was given every 3-4 weeks for six cycles in responding patients. Patients responding to the chemotherapy regimen were also treated with prophylactic cranial irradiation, and limited-stage patients received thoracic radiotherapy. The study population included 36 extensive-stage patients and 11 limited-disease patients with renal or cardiac disease that precluded standard chemotherapy. The median age of the study population was 69 years (range: 47-84).

RESULTS

Nine of 47 patients were inevaluable for response, including four patients who succumbed to sepsis. Of the 38 patients evaluable for response, 71% responded (95% CI: 56-86%) (88% LD; 67% ED) with a complete response in 29% of patients (50% LD; 23% ED). Based on an analysis of intent to treat, the overall response rate was 60% and the median survival time of the whole group was 46 weeks (LD, 59 weeks; ED, 45 weeks). Treatment was generally well tolerated. Neutropenia was the dose-limiting toxicity; the median nadir granulocyte count was 1.04 x 10(9)/L (range: 0-8.2).

CONCLUSION

We conclude that this regimen can provide palliation to SCLC patients who might not otherwise be considered for systemic chemotherapy.

Phase II study of docetaxel (taxotere) in patients with previously untreated extensive small cell lung cancer

The objective of this multicenter phase II study was to evaluate the activity of docetaxel in previously untreated small cell lung cancer. Fourteen patients were treated at a dose of 75 mg/m2 intravenously every three weeks. Of the 12 patients evaluable for response, one had a partial response for a duration of 12 weeks for a response rate of 8.3%. Toxicity was mild. We conclude that docetaxel has, at the dose given in this study, little activity in previously untreated small cell lung cancer.

Tick-bite fever in South Africa. The occurrence of severe cases on the Witwatersrand

Tick-bite fever, the variety of tick typhus occurring in southern Africa, is caused by Rickettsia conori var. pijperi and is transmitted by hard or ixodid ticks. It is usually a mild disease, especially in children and young adults, but in middle-aged and elderly patients (and sometimes in young adults) it may assume a severe form. This is characterized by high fever, severe headache, delirium, stupor and occasionally coma, and a profuse maculopapular rash which becomes haemorrhagic and is associated with petechiae in the skin and later, but rarely, by the development of gangrene of the fingers and toes. During these severe attacks the central nervous system may be involved and marked disorders of liver and kidney function sometimes lead to kidney failure and the need for treatment and dialysis in an intensive care unit. Three illustrative cases are described in which diagnosis was delayed. One patient died; 2 patients responded to administration of tetracycline. The danger of allowing tick-infested dogs onto one's bed is stressed. Infections transmitted by dog ticks tend to be more severe than those acquired via ticks from the bushveld, possibly because they so often occur in middle-aged and elderly patients. Serological tests have recently indicated that there are antigenic differences between 'suburban' and 'bushveld' strains; these clearly require further study.