Incidence, Treatment and Outcomes of Cervical Cancer in Low- and Middle-income Countries

Cervical cancer is one of the most common cancers in developing nations. It has had a tremendous impact on the lifetime of millions of women over the last century and continues to do so. In this collaborative clinicians' review, we highlight the incidence, treatment and clinical outcomes of cervical cancer in low-income (LICs) and low- and middle-income countries (LMICs) across Asia, South America, South Africa and Eastern Europe. With the cervical cancer burden and locally advanced cancers being high, the majority of LICs/LMICs have been striving to adhere to optimal evaluation and treatment guidelines. However, the huge gap in resource availability, rural versus urban disparity and access to resources have led to poor compliance to evaluation, treatment and post-treatment rehabilitation. To mitigate the overwhelming numbers, various treatment strategies like neoadjuvant chemotherapy, hypofractionation radiation schedules (both external and brachytherapy) have been attempted with no major success. Also, the compliance to concurrent chemoradiation in various regions is a major challenge. With the burden of advanced cancers, the lack of palliative care services and their integration in cancer care is still a reality.

POS0676 SURVIVAL OF THE FIRST COURSE OF BIOLOGIC OR JAK INHIBITOR IN RHEUMATOID ARTHRITIS: ASSOCIATION WITH THE CHOICE OF AGENT AND CONCOMITANT CONVENTIONAL SYNTHETIC DMARDS

Background:

After failure of conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) in the therapy of rheumatoid arthritis (RA), treatment may be escalated to biologic (bDMARDs) or JAK inhibitors (JAKi) (1). Analysis of drug survival can provide useful information on the effectiveness of these therapeutic schemes.

Objectives:

to evaluate the association of the choice of therapeutic agent with the survival of treatment course in RA patients receiving their first bDMARD or JAKi.

Methods:

BiobadaBrasil is a multicentric registry-based cohort study of Brazilian patients starting their first bDMARD/JAKi (2). This analysis includes RA patients recruited from Jan 2009 to Oct 2019, followed-up over the first course of treatment with a bDMARD/JAKi until censoring (latest date, Nov 19, 2019) or occurrence of the outcome of interest. A treatment course is defined as a period during which the medication scheme does not change, except for dose adjustments. The primary outcome was the interruption of treatment course for any reason (except for pregnancy or disease remission); interruption of treatment due to adverse events (AEs) or death and due to inefficacy served as secondary outcomes. Multivariate Cox proportional hazards models were used for analyses.

Results:

In total, 1177 patients (3800 patient-years [PY]) were enrolled. The overall incidence of treatment interruption was 17.5/100 PY. Adalimumab was the most frequently prescribed agent, followed by infliximab (n= 267). The hazards ratios (HR) of the primary and secondary outcomes are presented in Table 1. Figure 1 compares the survival of treatment curves of different bDMARDs/JAKi.

Table 1.

Hazard ratios (HR) of interruption of therapy course of each therapeutic agent (the reference category for bDMARDs/ JAKi is infliximab). Results are HR, 95% CIs, and P values*.

Agent (number of patients)Interruption for any reason (665 events)Interruption due to adverse events or death (196 events)Interruption due to inefficacy (319 events)Adalimumab (354)0.83 (0.68 to 1.01), P= 0.0620.68 (0.48 to 0.96), P=0.0291.08 (0.80 to 1.44), P=0.621Etanercept (257)0.81 (0.66 to 1.01), P=0.0630.56 (0.37 to 0.83), P=0.0040.93 (0.68 to 1.29), P=0.674Certolizumab (80)0.74 (0.47 to 1.16), P=0.1850.33 (0.13 to 0.86), P=0.0241.32 (0.74 to 2.35), P=0.350Golimumab (53)0.86 (0.53 to 1.38), P=0.5300.46 (0.18 to 1.19), P=0.1111.07 (0.53 to 2.15), P=0.849JAKi (tofacitinib) (59)0.54 (0.30 to 0.99), P=0.0470.19 (0.04 to 0.82), P=0.0260.89 (0.41 to 1.96), P=0.779Rituximab (48)0.87 (0.55 to 1.37), P=0.5400.48 (0.20 to 1.18), P=0.1090.58 (0.26 to 1.34), P=0.205Abatacept (30)0.52 (0.25 to 1.07), P=0.0770.46 (0.14 to 1.56), P=0.2150.46 (0.14 to 1.52), P=0.203Tocilizumab (29)0.29 (0.14 to 0.63), P=0.0020.40 (0.12 to 1.30), P=0.1260.28 (0.09 to 0.90), P=0.033Methotrexate (792)0.95 (0.79 to 1.14), P=0.5610.86 (0.62 to 1.19), P=0.3620.98 (0.75 to 1.28), P=0.860Leflunomide (497)1.17 (0.99 to 1.39), P=0.0611.44 (1.06 to 1.96), P=0.0201.02 (0.80 to 1.30), P=0.856Sulfasalazine (48)1.18 (0.80 to 1.75), P=0.4011.94 (1.07 to 3.54), P=0.0300.85 (0.45 to 1.59), P=0.605Antimalarials (230)0.80 (0.65 to 0.98), P=0.0270.67 (0.45 to 0.99), P=0.0430.67 (0.50 to 0.92), P=0.011

* All tests adjusted for other variables presented in the table and for age, baseline DAS28, disease duration, gender, smoking, seropositivity (RF/anti-CCP), previous malignancy, diabetes, hypertension, hypercholesterolemia, renal failure, ischemic cardiomyopathy, COPD, heart failure, use of corticosteroids, starting year, hypercholesterolemia, osteoporosis, hepatitis B and C.

Conclusion:

In our study, infliximab was related to an overall higher hazard of treatment course interruption than tolicizumab and tofacitinib, and higher hazard of interruption due to AEs than most other anti-TNF agents and tofacitinib. Maintaining antimalarials in patients receiving advanced therapies for RA may reduce interruption of treatment due to inefficacy and AEs.

Disclosure of Interests:

None declared

Introducing FDG PET/CT-guided chemoradiotherapy for stage III NSCLC in low- and middle-income countries: preliminary results from the IAEA PERTAIN trial

Purpose

Patients with stage III non-small-cell lung cancer (NSCLC) treated with chemoradiotherapy (CRT) in low- and middle-income countries (LMIC) continue to have a poor prognosis. It is known that FDG PET/CT improves staging, treatment selection and target volume delineation (TVD), and although its use has grown rapidly, it is still not widely available in LMIC. CRT is often used as sequential treatment, but is known to be more effective when given concurrently. The aim of the PERTAIN study was to assess the impact of introducing FDG PET/CT-guided concurrent CRT, supported by training and quality control (QC), on the overall survival (OS) and progression-free survival (PFS) of patients with stage III NSCLC.

Methods

The study included patients with stage III NSCLC from nine medical centres in seven countries. A retrospective cohort was managed according to local practices between January 2010 and July 2014, which involved only optional diagnostic FDG PET/CT for staging (not for TVD), followed by sequential or concurrent CRT. A prospective cohort between August 2015 and October 2018 was treated according to the study protocol including FDG PET/CT in treatment position for staging and multimodal TVD followed by concurrent CRT by specialists trained in protocol-specific TVD and with TVD QC. Kaplan–Meier analysis was used to assess OS and PFS in the retrospective and prospective cohorts.

Results

Guidelines for FDG PET/CT image acquisition and TVD were developed and published. All specialists involved in the PERTAIN study received training between June 2014 and May 2016. The PET/CT scanners used received EARL accreditation. In November 2018 a planned interim analysis was performed including 230 patients in the retrospective cohort with a median follow-up of 14 months and 128 patients in the prospective cohort, of whom 69 had a follow-up of at least 1 year. Using the Kaplan–Meier method, OS was significantly longer in the prospective cohort than in the retrospective cohort (23 vs. 14 months, p = 0.012). In addition, median PFS was significantly longer in the prospective cohort than in the retrospective cohort (17 vs. 11 months, p = 0.012).

Conclusion

In the PERTAIN study, the preliminary results indicate that introducing FDG PET/CT-guided concurrent CRT for patients with stage III NSCLC in LMIC resulted in a significant improvement in OS and PFS. The final study results based on complete data are expected in 2020.

Electronic supplementary material

The online version of this article (10.1007/s00259-019-04421-5) contains supplementary material, which is available to authorized users.

Listening to doctors on patients' use of healthcare during the crisis: uncovering a different picture and drawing lessons from Portugal

Background

The consequences of financial crises on patients' use of healthcare have been widely discussed. This paper seeks to ascertain whether the position of key players, i.e. doctors, may reveal realities other than those officially reported about the 2008 financial crisis.

Methods

In 2013-14, a national survey of doctors was conducted in Portugal, which received international assistance in the wake of the financial crisis. An exploratory model comprising descriptive statistics, regression and independence analyses focused on doctors' experience of patients' use of medications, consultations, exams and treatment services, and whether they stopped treatments.

Results

According to doctors, an unspecified number of patients experienced difficulties using healthcare as more patients requested prescriptions for cheaper medications or simply stopped treatments. Significant variations were found according to speciality, years of practice and sector of activity.

Conclusions

Cost-containment mechanisms are regarded as necessary. However, the evidence indicated a side effect, i.e. a decrease in patients' ability to use healthcare, including in the National Health Service (NHS). It also highlighted the need to listen to health professionals as key informants on patient's behaviour and the daily functioning of health services.

Is it a (fe)male pain? Portuguese nurses' and laypeople's gendered representations of common pains

BACKGROUND

Although many studies have explored gender role expectations of pain behaviours in different cultures, only a few authors have tried to explore whether certain pains are more associated with the typical man or woman. Hence, this study aimed at exploring, among Portuguese laypeople and nurses, patterns of common pains more strongly associated with the typical man or woman, and their relationship with health-care training and personal pain experiences.

METHODS

A total of 68 nurses (76% women) and 55 laypeople (62% women) were asked to identify, through free association, the most frequent common pains that people in general associate with the typical man and woman, respectively, and also to report their personal past pain experiences. A content analysis was used to categorize and quantify participants' responses. A multiple correspondence analysis was performed to identify gendered patterns of common pains, followed by a cluster analysis to classify participants according to their endorsed patterns.

RESULTS

Findings showed that while 'back and musculoskeletal pains' was the only pattern associated with the typical man, more differentiated patterns of pains were associated with the typical woman, namely (1) headaches; (2) abdominal, back and musculoskeletal pains; and (3) pains due to hormonal cycles, labour/puerperium and from the urinary/reproductive system. These representations were shared by laypeople and nurses and were only significantly associated with personal experiences of pains from the urinary/reproductive system.

CONCLUSIONS

This study identified different gendered patterns of common pains, which may have important implications for (wo)men's pain experiences and how these are interpreted by others.

Increased expression and purification of soluble iron-regulatory protein 1 from Escherichia coli co-expressing chaperonins GroES and GroEL

Iron is an essential metal for all living organisms. However, iron homeostasis needs to be tightly controlled since iron can mediate the production of reactive oxygen species, which can damage cell components and compromise the integrity and/or cause DNA mutations, ultimately leading to cancer. In eukaryotes, iron-regulatory protein 1 (IRP1) plays a central role in the control of intracellular iron homeostasis. This occurs by interaction of IRP1 with iron-responsive element regions at 5' of ferritin mRNA and 3' of transferrin mRNA which, respectively, represses translation and increases mRNA stability. We have expressed IRP1 using the plasmid pT7-His-hIRP1, which codifies for human IRP1 attached to an NH2-terminal 6-His tag. IRP1 was expressed in Escherichia coli using the strategy of co-expressing chaperonins GroES and GroEL, in order to circumvent inclusion body formation and increase the yield of soluble protein. The protein co-expressed with these chaperonins was obtained mostly in the soluble form, which greatly increased the efficiency of protein purification. Metal affinity and FPLC ion exchange chromatography were used in order to obtain highly purified IRP1. Purified protein was biologically active, as assessed by electrophoretic mobility shift assay, and could be converted to the cytoplasmic aconitase form. These results corroborate previous studies, which suggest the use of folding catalysts as a powerful strategy to increase protein solubility when expressing heterologous proteins in E. coli.

Seasonal reproduction in the mare: possible role of plasma leptin, body weight and immune status

The primary objective of this study was to evaluate the possible role of leptin, body weight and immune status on reproductive activity throughout the transition period from cyclicity to seasonal anestrus, during anestrus and resumption of ovarian activity in Lusitano mares. Mares in good body condition were monthly monitored throughout 2 years (10 mares in each year) for evaluation of their reproductive status by sequential ultrasonography and plasma progesterone determinations. On the second year, all mares were weighed. Progesterone and leptin were assayed by radioimmunoassay (RIA). Parameters of the immune status (phagocytosis and oxidative burst of neutrophils, characterisation of circulating lymphocyte subsets) were also evaluated. Phagocytosis and oxidative burst in blood neutrophils were measured by flow cytometry using commercially available kits. Lymphocyte subsets were assessed by indirect immunofluorescence staining after incubation with monoclonal antibodies specific for CD2, CD19, CD4, CD8 cells markers by flow cytometry. Natural killer cells and B cells were estimated mathematically. No significant difference was found in phagocytosis, oxidative burst and circulating lymphocyte subsets at anestrus and at either phase of the estrous cycle (p>0.05), suggesting that the immune status of the mare was not influenced by the seasonal changes in ovarian activity. This study also suggests that body weight has a direct relationship with plasma leptin levels. Increased concentrations of this hormone in circulation might be associated with the restart or maintenance of ovarian cyclicity in Lusitano mares.

[Stereotactic radiosurgery in the intracranial benign neoplasms and malignant tumors of the brain]

Stereotactic Radiosurgery has proven to be during the last years the therapy of choice in more and more patients with benign and malignant brain tumors. The potential advantages comparatively to surgery and conventional radiotherapy made this technique a very important tool in the therapeutic armamentarium of neurooncology. This series presents the experience of treating more than 100 intracranial lesions with linear accelerator-based radiosurgery at Hospital de Santa Maria in Lisbon with special emphasis on the indications and results. It also provides a review of the concepts and procedures of this modality as well as a general overview of the main published results in series of patients with brain tumors treated with stereotactic radiosurgery.

Peripheral blood neutrophil function and lymphocyte subpopulations in cycling mares

The purpose of this study was to evaluate different parameters of the immune status in the mare, during the follicular and the luteal phases of the oestrous cycle, in two consecutive years. Functional competence of peripheral blood neutrophils, such as chemotaxis, phagocytosis and oxidative burst was assessed under physiological cyclic conditions (Exp. I). In the second year of this study (Exp. II), besides peripheral blood neutrophil phagocytosis and oxidative burst analysis, circulating lymphocyte subsets were also characterized. The reproductive status in a total of 17 adult cycling mares was evaluated by ultrasonography and further confirmed by plasma progesterone levels. Chemotaxis tests were performed using porous membranes inserted in transwell chambers. Lipopolysaccharide (LPS) from Escherichia coli and N-formyl-Met-Leu-Phe (fMLP) were used as chemoattractants. Measurement of phagocytosis and oxidative burst in blood neutrophils were assessed by flow cytometry using commercially available kits. Quantification of T-lymphocyte subsets was assessed by indirect immunofluorescence staining after incubation with monoclonal antibodies specific for CD2, CD3, CD4 and CD8 cell markers by flow cytometry. Natural killer cells and B cells were estimated mathematically. No significant difference was found in migration, phagocytosis and oxidative burst at either phase of the oestrous cycle. Statistical analysis of total white blood cell counts also showed no significant difference between either phase of the oestrous cycle, although there was a tendency for blood neutrophils to increase in number under the progesterone influence (p = 0.09). Lymphocytic subpopulations did not differ throughout the oestrous cycle. Overall, our results suggest that luteal and follicular phases in cycling mares may not influence the immune status of the mare.

Filtration induces changes in activity states and leucocyte populations

The distribution of leucocyte subpopulations in platelet concentrates (PC) derived from pre-storage filtered platelet-rich plasma (PRP), the cell suspension obtained by reverse filter washing and the post-filtered PC, were monitored by immunophenotyping analysis using CD3, CD20 and CD33. Leucocyte activation analysis with the CD11b marker revealed that this molecule is up regulated in neutrophils taken from the filter. This, together with the loss of cell viability during the enrichment process, suggests that contact with the filter matrix and processing and storage of samples containing leucocytes may lead to activation and loss of leucocyte viability. These changes were found to be more pronounced in less stable myeloid cells and account for the differences reported among various authors which in some cases related to operational conditions such as the enrichment process used and the length of time between filtration and analysis of samples. Finally, statistical analysis of the results obtained by immunophenotypic studies indicate that post-filter samples (S) contain significantly higher numbers of CD33+ myeloid cells when compared to (PF) the pre-filter samples (65.03%+/-12.6 and 24.56%+/-14.73, p<0.0000), with a decrease in T cells (50.72%+/-14.80 in PF and 24.05+/-9.48 in the cell suspension (S), p<0.0007) and B cells (14.96+/-9.31 in PF and 9.9+/-5.22 in S, p<0.201). A new strategy for assessing the influence of the filtration process on residual leucocyte activation and viability is described. This has direct relevance to collection, processing, storage and quality monitoring of PC.

Blood and intrauterine leukocyte profile and function in dairy cows that spontaneously recovered from postpartum endometritis

The profile and function of blood and uterine leukocytes were evaluated in 14 dairy cows that spontaneously recovered from postpartum endometritis (mild, n=6 and heavy, n=8; general health not affected). From a minimum of 2 weeks before parturition until 6 weeks postpartum, blood samples were obtained twice weekly for leukocyte counts and leukogram determination and once weekly for flow cytometry assessment of polimorphonuclear neutrophils (PMN) phagocytic capacity and oxidative burst activity. Uterine fluid-stained smears, obtained twice weekly from parturition until fluid was present in the uterus, were used for determination of the percentage of PMN, of phagocytizing PMN (phago-PMN) and of the mean number of phagocyted bacteria per phagocytizing PMN (phagocytic index; PI). Uterine swabs were obtained twice weekly from parturition until 35 days postpartum for bacteriological examination. The time of endometritis diagnosis was similar in cows with mild or heavy endometritis but the latter cows had a significantly longer persistence of the infection and of the isolation of Gram-negative anaerobes from the uterus. However, the effect of group (mild versus heavy) was not significant for all the blood and uterine parameters analysed. The effect of sampling day (within group effect) was significant (p<0.01 to p<0.00001) for all parameters, except for the blood monocyte count and the blood PMN phagocytic capacity, in which only a tendency for significance was observed (p<0.1). The effect of the interaction group x sampling day was significant only for the blood monocyte count. The phago-PMN and the PI were significantly correlated (r=0.70, p<0.001). A significant correlation was also observed between the uterine fluid phago-PMN and the blood PMN oxidative burst activity (r=-0.41, p<0.05). At the spontaneous recovery, the blood PMN oxidative burst activity was significantly higher (p<0.05) and the percentage of intrauterine phago-PMN and the PI were significantly lower (p<0.001 and p<0.01, respectively) than at diagnosis of endometritis. These results suggest that a decrease in blood PMN oxidative burst activity until the first week postpartum could be associated with an increased susceptibility to early postpartum endometritis. The later increase in this parameter as well as the increase in the intrauterine fluid phago-PMN and PI, might favour the spontaneous resolution of endometritis.

Use of stents for small coronary arteries. Results of the Multi-Link 2.5 Portuguese Registry

INTRODUCTION

Stents are being used with increasing frequency in percutaneous transluminal coronary angioplasty (PTCA) but their use in small vessels is still controversial, due to the possibility of excessively high rates of adverse events and restenosis.

OBJECTIVE

To assess the safety and clinical efficacy of ACS RX Multi-Link (ML) 2.5 mm stents, in "de novo" coronary stenosis.

DESIGN

Prospective Registry, with 6 months clinical follow-up, involving all Portuguese centers of Interventional Cardiology.

POPULATION

Between April 7 and November 20 1998, 102 patients were enrolled, 82 male and with ages ranging from 30 to 86 years (average 58 +/- 11). Clinical presentation for PTCA was stable angina in 53%, unstable angina in 36% and silent ischemia in 11%. There was a history of previous myocardial infarction in 29% of patients. The main risk factors were hypertension (58%), hyperlipidemia (57%), smoking (25%) and diabetes (20%). Multivessel coronary artery disease was present in 46% of patients and left ventricular function was normal in 89%. Of the 217 existing lesions, 188 (87%) were treated: 35 with balloon angioplasty and 153 with stent implantation, 114 of which were ML 2.5 mm: 79 of 15 mm in length and 35 of 25 mm.

METHODS

Angiographic success with ML stent implantation and major adverse cardiac events (MACE)--myocardial infarction (MI), coronary artery bypass graft (CABG), new target vessel revascularizations and death--were evaluated during hospital stay, and at 1 and 6 months clinical follow-up.

RESULTS

Angiographic success was 97.4%. In one patient it was not possible to cross the lesion, in another there was stent migration and in a third distal coronary flow after stenting was TIMI grade 1. Clinical success was 96.1% and there were no cases of death, Q-wave MI or urgent CABG. Two patients had non-Q wave MI and two required urgent repeat angioplasty. Subacute stent thrombosis occurred in 1 patient. There were no additional MACE at 1 month follow-up. At 6-month follow-up (in 97% of patients) MACE had occurred in 14.1%: 2 deaths (one non-cardiac), 3 MI (one non-Q) and 14 new PTCA (one in a non-ML stent). There was no need for CABG in any patient. Six-month survival rate was 97.9%, 94.9% were free of infarction and 84.8% were free of infarction and new revascularization.

CONCLUSIONS

Multi-Link 2.5 mm stent implantation appears to be safe and efficient with a low incidence of immediate and 6-month adverse events in the range of centers and operators of the Registry.

Transradial approach for coronary interventions

OBJECTIVE

To assess the feasibility and safety of coronary interventions performed through the radial artery.

METHODS

We studied 103 patients with ages from 38 to 86 years (57+/-8.7), 90 (87%) males, and: radial pulse with a good amplitude, presence of ulnar pulse, a good collateral flow through the palmar arch assessed with the Allen's test.

RESULTS

The vascular approach was obtained in 97 (94%) patients, 88 (91%) treated electively and 9 (9%) during acute myocardial infarction, for primary angioplasty; 56 (64%) unstable angina; 22 (25%) stable angina; 10 (11%) were asymptomatic, 6 referred for recanalization of chronic occlusion and 4 silent ischemia in the first week after acute myocardial infarction. We approached 107 arteries: anterior descending artery, 49 (46%); right coronary artery, 27 (25%); circumflex artery, 25 (23%); diagonal artery, 6 (6%); and 2 saphenous vein bypass grafts. We treated 129 lesions: 80 (62%) B2 type; 23 (18%) B1 type; 17 (13%) C type; and 9 (7%). A type. There were 70 stents, and 59 balloon angioplasties performed. Thirty-two (33%) patients used GP IIb/IIIa inhibitors. The mean duration of the elective procedure was 42.3+/-12.8 min. Success, correct stent deployment and residual lesion <20%, was reached in 100% of the lesions treated with stent implantation; arterial dilation with residual lesion <50% was obtained in 96% of the lesions treated with transluminal coronary angioplasty (TCA). Complications, were: 1 (1.0%) non-Q-wave acute myocardial infarction; 2 (2%) hematomas in the forearm; and 2 losses of radial pulse.

CONCLUSION

Radial artery approach is practical and safe for percutaneous coronary interventions there was a low incidence of complications.

Differential expression of the two cytosolic glutamine synthetase genes in various organs of Medicago truncatula

In order to clarify the physiological roles of the cytosolic forms of glutamine synthetase (GS) in Medicago truncatula, we have performed a detailed analysis of the expression of the two functional cytosolic GS genes, MtGSa and MtGSb in several organs of the plant. Transcriptional fusions were made between the 2.6 or 3.1 kbp 5' upstream regions of MtGSa or MtGSb, respectively, and the reporter gene gusA encoding beta-glucuronidase and introduced into the homologous transgenic system. MtGSa and MtGSb were found to be differentially expressed in most of the organs, both temporally and spatially. The presence of GS proteins at the sites where the promoters were active was confirmed by immunocytochemistry, providing the means to correlate gene expression with the protein products. These studies have shown that the putative MtGSa and MtGSb promoter fragments were sufficient to drive GUS expression in all the tissues and cell types where cytosolic GS proteins were located. This result indicates that the cis acting regulatory elements responsible for conferring the contrasting expression patterns are located within the region upstream of the coding sequences. MtGSa was preferentially expressed in the vascular tissues of almost all the organs examined, whereas MtGSb was preferentially expressed in the root cortex and in leaf pulvini. The location and high abundance of GS in the vascular tissues of almost all the organs analysed suggest that the enzyme encoded by MtGSa plays an important role in the production of nitrogen transport compounds. The enzyme synthesised by MtGSb appears to have more ubiquitous functions for ammonium assimilation and detoxification in a variety of organs.

Correlation between HIV and HCV in Brazilian prisoners: evidence for parenteral transmission inside prison

OBJECTIVE

It is an accepted fact that confinement conditions increase the risk of some infections related to sexual and/or injecting drugs practices. Mathematical techniques were applied to estimate time-dependent incidence densities of HIV infection among inmates.

METHODS

A total of 631 prisoners from a Brazilian prison with 4,900 inmates at that time were interviewed and their blood drawn. Risky behavior for HIV infection was analyzed, and serological tests for HIV, hepatitis C and syphilis were performed, intended as surrogates for parenteral and sexual HIV transmission, respectively. Mathematical techniques were used to estimate the incidence density ratio, as related to the time of imprisonment.

RESULTS

Prevalence were: HIV - 16%; HCV - 34%; and syphilis - 18%. The main risk behaviors related to HIV infection were HCV prevalence (OR=10.49) and the acknowledged use of injecting drugs (OR=3.36). Incidence density ratio derivation showed that the risk of acquiring HIV infection increases with the time of imprisonment, peaking around three years after incarceration.

CONCLUSIONS

The correlation between HIV and HCV seroprevalence and the results of the mathematical analysis suggest that HIV transmission in this population is predominantly due to parenteral exposure by injecting drug, and that it increases with time of imprisonment.

Cellular expression and regulation of the Medicago truncatula cytosolic glutamine synthetase genes in root nodules

In this paper we have studied the localisation of expression of the two functional cytosolic glutamine synthetase (GS) genes, MtGSa and MtGSb, in root nodules of the model legume Medicago truncatula. We have used a combination of different techniques, including immunocytochemistry, in situ hybridisation and promoter beta-glucuronidase (GUS) fusions in transgenic plants, to provide the means of correlating gene expression with protein localisation. These studies revealed that transcriptional regulation (mRNA synthesis) plays an important part in controlling GS protein levels in nodules of M. truncatula. The major locations of cytosolic GS mRNA and protein are the central tissue, the parenchyma and the pericycle of the vascular bundles. These findings indicate that in nodules, GS might be involved in other physiological processes in addition to the primary assimilation of ammonia released by the bacterial nitrogenase. The two genes show different but overlapping patterns of expression with MtGSa being the major gene expressed in the infected cells of the nodule. Promoter fragments of 2.6 kb and 3.1 kb of MtGSa and MtGSb, respectively, have been sequenced and primer extension revealed that the MtGSb promoter is expressed in nodules from an additional start site that is not used in roots. Generally these fragments in the homologous transgenic system were sufficient to drive GUS expression in almost all the tissues and cell types where GS proteins and transcripts are located except that the MtGSa promoter fragment did not express GUS highly in the nodule infected cells. These results indicate that the cis-acting regulatory elements responsible for infected-cell expression are missing from the MtGSa promoter fragment.

Haem precursor delta-aminolaevulinic acid induces activation of the cytosolic iron regulatory protein 1

Control of cellular iron homoeostasis is performed by iron regulatory protein 1 (IRP1) through post-transcriptional modifications. This protein is sensitive to intracellular iron availability, being activated at low iron levels and inactivated at high iron levels, conditions that signal the increased expression of the transferrin receptor or of ferritin respectively. IRP1 is known to be activated by some oxidants such as H2O2 and NO. delta-Aminolaevulinic acid (ALA), previously found to produce reactive oxygen species and a carbon-centred radical, to release iron from ferritin, and to increase rat liver and brain non-haem iron and ferritin, was investigated for its effects on IRP1 activity in cultured hamster pulmonary fibroblasts. We have found that 1-2 mM ALA produced a 2-3-fold activation of IRP. On incubation with 1-4 mM succinylacetone methyl ester, a potent ALA dehydratase inhibitor, a 3-4-fold activation of the protein was observed, accompanied by a 40% increase in the intracellular ALA concentration. When cells were incubated in the presence of ALA or succinylacetone methyl ester, N-acetylcysteine inhibited IRP1 activation, suggesting that the observed effect is mediated by an oxidative process. We surmise that ALA-induced IRP1 activation might act as a co-sensor of iron homoeostasis.

Heteromeric assembly of the cytosolic glutamine synthetase polypeptides of Medicago truncatula: complementation of a glnA Escherichia coli mutant with a plant domain-swapped enzyme

We have cloned and sequenced the cDNAs corresponding to the two cytosolic glutamine synthetase (GS) polypeptides (a and b) of Medicago truncatula. Using these two cDNAs we have prepared a construct encoding the N-terminal domain of b and the C-terminal domain of a in order to produce a domain-swapped polypeptide which should assemble to give an enzyme containing chimeric active sites. Both the native and the domain-swapped enzymes were expressed in Escherichia coli where they were catalytically and physiologically active as they were able to rescue a glnA deletion mutant. The expressed polypeptides were of the correct size and the isoenzymes behaved similarly to their native homologues on ion-exchange chromatography. We have found slight differences in the kinetic properties of the purified enzymes and in the modulation of their activities by several putative cellular effectors. In vitro dissociation of the purified a and b homo-octamers, followed by reassociation, showed that the subunits are able to self-assemble, perhaps randomly, to form heteromeric isoenzymes. Moreover, heteromeric isoenzymes occur in the plant as revealed by studies on the GS isoenzymes of nodules, roots, stems and stipules.

[A methodology for the diagnosis and follow-up of the evolution of acute hepatitis in childhood. The Working Group of the Section of Pediatric Gastroenterology and Nutrition of the Portuguese Pediatrics Society]

The Working Group of the Section of Paediatric Gastroenterology and Nutrition of the Portuguese Society of Paediatrics established a protocol for the investigation of children with acute hepatitis. The main purpose of this proposal is to allow appropriate etiologic investigations and avoid unnecessary tests that are expensive and do not add relevant information for the correct follow-up of these patients.

[Mitral valvuloplasty with Inoue balloon catheter. Analysis of 112 cases]

PURPOSE

To present immediate results of percutaneous mitral valvuloplasty (PVM) with Inoue balloon for the treatment of mitral stenosis.

METHODS

One hundred and twelve consecutive patients mean age 31.26 +/- 9.5 years, 82% females, the majority in functional class III/IV (69%) underwent percutaneous mitral valvuloplasty (PVM) with Inoue balloon. The procedure was undertaken by the transseptal technique.

RESULTS

PMV achieved significant reduction in mean left atrial pressure pre 24.57 +/- 5.37 post 12.36 +/- 4.82, mitral gradient pre 15.31 +/- 4.28 post 3.48 +/- 2.09 and increased mitral valve area pre 0.88 +/- 0.12 post 2.0 +/- 0.28 (P < 0.001). An increase of at least 25% of the mitral valve area with a final result greater than 1.5 cm2 was obtained in 96% of the cases. Cardiac tamponade occurred in five cases (4.4%). In 4 a successful treatment was accomplished in the catheterization laboratory. Significant mitral regurgitation was seen in one case (0.9%) and there was one death (0.9%).

CONCLUSION

The results of this series attest to the effectiveness of the PMV with Inoue balloon in selected cases of mitral stenosis.

Detection of a Cytosolic Glutamine Synthetase in Leaves of Nicotiana tabacum L. by Immunocytochemical Methods

Two glutamine synthetase (GS) polypeptides (44 and 39 kD) were immunodetected on western blots of leaf extracts from tobacco (Nicotiana tabacum L.), a plant that has been reported to contain only chloroplast GS in the leaves. By immunocytochemical methods, we confirmed the localization of GS in the cytosol of cells in the vascular tissue and in the chloroplasts of mesophyll cells.

[Value of transesophageal echocardiography in the diagnosis of acute aortic dissection]

We describe our experience of six patients with clinical suspicion of acute aortic dissection (AAD) who were studied consecutively by transesophageal echocardiography (TEE) from April to July of 1991. All of them were previously submitted to transthoracic echocardiogram. The diagnosis was correctly established by TEE in five cases, confirmed by aortography and/or surgery (four cases), or by autopsy (one case). In one patient the diagnosis of AAD was excluded by TEE, and posteriorly by nuclear magnetic resonance. Four patients had a Stanford type A, and one patient a type B dissection. The site of entry was identified in three cases; the intimal entry tear of the type B dissection, not observed by TEE, was localized in the aortic arch by aortography. In three of the four type A dissection cases, a thrombus in the false lumen and an aortic regurgitation were found. No other noninvasive methods were used after the diagnosis of AAD by TEE. The surgical repair was successful in three cases, one of which, without previous necessity of aortography. In our experience, TEE increased extraordinarily the diagnosis efficacy of AAD, making possible an earlier therapeutic approach, and probably contributing to the improvement of the prognosis of this pathology.

[Coronary angioplasty using last generation materials. Immediate results]

PURPOSE

To present immediate results of percutaneous transluminal coronary angioplasty (PTCA) with the use of last generation catheter devices.

METHODS

74 patients underwent PTCA mean age 55 years the majority of them with disease of one vessel (92%) and good left ventricular function (88%). There was a total of 80 lesions treated, 26 type A and 54 type B according to the Task Force for Coronary Angioplasty of the American College of Cardiology--American Heart Association Classification. Results were analysed by separate observers: one clinical cardiologist (C), one cardiovascular surgeon (S) and two hemodynamicists (H1, H2).

RESULTS

A significant fail in the degree of coronary obstruction was demonstrated post PTCA in the opinion of the observers: C = 83 +/- 10.7/9.0 +/- 14; S = 86 +/- 13.0/9.3 +/- 11; H1 = 88.6 +/- 7.0/8.5 +/- 12; H2 = 88.5 +/- 8.0/8.3 +/- 12 (P less than 0.001). Angiographic success was attained in 94.6% of the cases and the complication rate was low 2.7%.

CONCLUSION

The high primary success and the low complication rates seen in this series can be attributed to the careful selection of cases and advanced performance of the catheterization devices that were used.

[Pericarditis caused by cholesterol. Apropos of a clinical case]

A case of a 76 year-old woman with a large pericardial effusion is described. The microscopic examination of the scintillating, yellow-greenish fluid obtained by the first pericardiocentesis, showed numerous crystals of cholesterol. In search of the underlying diseases there were found values of T3, T4 and TSH diagnostic of hypothyroidism. Considering the rapid relapse of the effusion and after a second pericardiocentesis, it was decided to open a pleuro-pericardial window. The biopsy of the pericardium showed deposits of cholesterol on electronics microscopy. She was discharged from hospital two weeks after surgery, showing an evident clinical improvement. Six months later she was feeling well, keeping a normal activity for her age. The values of T3, T4 and TSH were normal, and there were no echocardiographic signs of pericardial effusion. It is presented a rare case of cholesterol pericarditis associated to sub-clinical hypothyroidism, showing the presence of cholesterol, as crystals in the pericardial effusion and, we think for the first time in this pathology, in vesicles of pinocytosis, in the pericardial biopsy. The six months period of follow-up showed a good clinical improvement with the selected therapeutic attitude.