Distinct profiles of immune cell populations underlie in-stent restenosis: a cluster analysis approach

Background

In-stent restenosis (ISR) is a major challenge in patients with coronary artery disease due to its association with poor clinical outcomes, quality of life and costs. ISR etiopathogenesis remains unclear, but traditional risk factors cannot fully explain ISR burden. Inflammation-driven loss of endothelial homeostasis and neoatherosclerosis are thought to hallmark ISR. Recently, a number of immune cell subsets have been related to vascular repair failure and endothelial damage, such as angiogenic T-cells (Tang), endothelial progenitor cells (EPC), senescent T-cells (CD4+CD28null), monocyte subsets and low-density granulocytes (LDG). However, these subsets have not been studied in ISR and an integrative analysis is lacking.

Purpose

1) to evaluate potential alterations in vascular repair and endothelial damage cellular mediators in ISR and 2) to identify profiles associated with clinical features.

Methods

Case-control study including 30 patients with ≥1 previous stent implantation (15 bare metal stents (BMS) and 15 drug-eluting stents (DE)) which suffered restenosis and 30 patients with ≥1 BMS without restenosis, both confirmed in a second angiogram performed by clinical symptoms >8 months after index procedure. Cellular mediators of vascular homeostasis were quantified by flow cytometry based on their surface markers in peripheral blood (EPC: CD34+VEGFR2+CD133+; EC: CD34-VEGFR+CD133-; Tang: CD3+CD31+CXCR4+; senescent T-cells: CD4+CD28null) or in peripheral blood mononuclear cells (monocyte subsets, ACE expression; total LDG: CD15+; and LDG subsets: CD15+CD14-CD16- and CD15+CD14lowCD16+).

Results

Patients with ISR exhibited decreased circulating Tang (p=0.005) and EPC (p<0.001), whereas CD4+CD28null and EC counts were higher (p<0.0001 and p=0.006) compared to ISR-free patients. No differences were observed in the frequency of monocyte subsets (all p>0.050), although ACE expression was found to be increased (non-classical p<0.001; and intermediate p<0.0001) in ISR. Moreover, no differences were noted in the total LDG population (p=0.092), but an increase in the CD14- compartment was observed in ISR (p=0.004).

An unsupervised cluster analysis built with these subsets informed the presence of three profiles (Figure 1): group I (hallmarked by a profound impairment in vascular repair and augmented damage, suggestive of central haematopoiesis traits) exhibited an enhanced clinical risk profile compared to group II (hallmarked by a mid-altered vascular repair) and group III (hallmarked by CD16+ shifted LDG and ACE expression) (Figure 2). No differences were observed in stent types or traditional risk factors but hypertension.

Conclusions

Profound alterations in immune populations related to vascular repair and endothelial damage are found in ISR. Distinct cellular profiles can be distinguished within ISR, suggesting that different alterations may uncover different ISR clinical phenotypes, in terms of severity and extension.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ISCIIIPrograma Intramural ISPA Figure 1Figure 2

Antithrombotic strategies in elderly patients with atrial fibrillation revascularized with drug-eluting stents: PACO-PCI (EPIC-15) registry

Background

The strategy of antithrombotic therapy in patients with atrial fibrillation (AF) after revascularization with drug-eluting stents continues to be debated. The evidence in elderly population in this scenario is particularly scarce.

Purpose

We sought to investigate the antithrombotic regimens applied and their prognostic effects in patients over 75 years old with AF after revascularization with drug-eluting stents.

Methods

Retrospective registry in 20 centers including consecutive patients over 75 years with AF treated with drug-eluting stents. A primary endpoint of MACCE and a co-primary endpoint of major bleeding by ISTH criteria were considered at 12 months.

Results

Out of 41,000 patients undergoing PCI 1,249 patients (81.1±4.2 years, 33.1% women, 66.6% ACS, 30.6% complex PCI) were included. Triple antithrombotic therapy (TAT) was prescribed in 81.7% and dual antithrombotic therapy (DAT) in 18.3%. TAT was based on direct oral anticoagulants (DOAC) in 48.4% and maintained for only 1 month in 52.2%, and DAT included DOAC in 70.6%. Primary endpoint of MACCE was met in 9.6% and primary endpoint of major bleeding in 9.4%. TAT was significantly associated with more bleeding (10.2% vs. 6.1%, p=0.04) but less MACCE (8.7% vs. 13.6%, p=0.02) than DAT and the use of DOAC was significantly associated to less bleeding (8% vs. 11.1%, p=0.03) and similar MACCE (9.8% vs. 9.4%, p=0.8). TAT over 1 month or with VKA was associated with more major bleeding but comparable MACCE rates.

Conclusions

Despite advanced age TAT prevails, but prolonged durations or use of VKA are associated with increased bleeding without additional MACCE prevention. DAT reduces bleeding but with a trade-off in terms of ischemic events. DOAC use was significantly associated to less bleeding and similar MACCE rates.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Bristol-Myers-Squibb/Pfizer

Spontaneous coronary artery dissection in the elderly: clinical features, angiographic findings, management and outcomes

Background

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). Clinical features, angiographic findings, management and outcomes of SCAD in elderly patients remain unknown.

Methods

The Spanish multicenter prospective SCAD registry included 318 consecutive patients with SCAD diagnosis. Patients were classified according to age in two groups: <65 and ≥65 years old.

Results

A total of 55 patients (17%) were 65 or older (Table). Elderly patients had more often hypertension (29% vs 76%, p<0.01) and dyslipidemia (30% vs 56%, p<0.01), and less smoking history (51% vs 7%, p<0.01). Previous history of coronary artery disease was also more frequent in older patients (4% vs 11%, p=0.044). Interestingly, an identifiable trigger was more often found among patients under 65. Coronary artery tortuosity (1±0.99 vs 1.4±1, p=0.027) and coronary artery ectasia (9% vs 24%, p<0.01) were both more frequent in elderly patients, who were more often managed conservatively (75% vs 89%, p=0.025). A trend toward a higher mortality rate was found among patients ≥65, with no differences in terms of in hospital stay, new acute myocardial infarction, unplanned coronariography or heart failure.

Conclusions

Elderly patients with SCAD show different clinical and angiographic characteristics and they receive distinct management. Short-term outcomes do not significantly differ from those seen in younger patients.

Funding Acknowledgement

Type of funding source: None

P5425Prognostic value of NYHA functional class in heart failure patients undergoing primary prevention implantable cardioverter defibrillator therapy

Background

NYHA functional class (FC) is used for selection of heart failure (HF) patients who are candidates to primary prevention (PP) implantable cardioverter defibrillator (ICD) therapy. However, FC is subjectively estimated and concerns about its real prognostic value are still present in this setting.

Purpose

To compare whether mortality and arrhythmic risk are different, in a cohort of HF patients undergoing PP ICD-only implant, according to their FC.

Methods

All HF patients with left ventricle ejection fraction (LVEF) ≤35%, undergoing first prophylactic ICD-only implant were collected from the UMBRELLA nationwide registry (2006–2015). The sample was divided into three groups: no symptoms (NYHA I), mildly symptomatic patients (NYHA II) and severely symptomatic (NYHA III) patients. Outcomes were studied as follow: all-cause death, cardiovascular mortality and arrhythmia free survival (surrogate marker of sudden cardiac death) defined as survival free of first appropriate ICD therapy delivered in ventricular fibrillation (VF) window. Arrhythmic events were collected by remote monitoring and reviewed by a committee of experts.

Results

Six hundred and twenty one patients were identified (61.1±11.4 years, 87.3% male). Distribution of study groups was as follow: 101 patients in NYHA I; 411 in NYHA II; and 109 in NYHA III. More symptomatic patients were older and had higher prevalence of atrial fibrillation (AF) and chronic kidney disease (CKD). Higher rates of optimal medical treatment were present among study groups (beta-blockers: 92.1%; ACEI or ARB: 86.8%; aldosterone antagonists: 60.2%). After a median follow-up of 4.2 years (IQR, 2.7–5.7 years) 126 patients died (event rate: 20.3%). All-cause mortality was higher in patients with worse FC (13.9% vs. 18.3% vs. 32.9% for NYHA I, II and III respectively; p<0.001, log-rank test). Seventy-eight out of 126 deaths were related to cardiovascular causes (overall event rate: 12.6%). Cardiovascular mortality risk was also higher in more symptomatic patients (6.9% vs. 11% vs. 23.9% for NYHA I, II and III respectively; p<0.001, log-rank test). One hundred and seventeen patients received afirst appropriate ICD therapy (19.4%). Arrhythmia free survival was not different among study groups (20.8% vs. 18.7% vs. 20.8% for NYHA I, II and III, respectively; p=0.495, log-rank test). Cumulative incidence curves for the three outcomes are shown in Figure 1. After multivariate analysis, worse NYHA class independently predicted cardiovascular mortality but not all-cause death. Moreover, diabetes, AF and CKD strongly predicted both all-cause and cardiovascular mortality.

Figure 1

Conclusions

In HF patients, prophylactic ICD seems to be useful in preventing death due to life threatening arrhythmias, regardless of the baseline FC. Nevertheless, the combination of NYHA class with other comorbidities may be useful to select those ICD candidates who obtain less survival benefit.

The diversity of the human hair colour assessed by visual scales and instrumental measurements. A worldwide survey

OBJECTIVES

To study (i) the diversity of the natural colour of the human hair through both visual assessment of hair tone levels and colorimetric measurements of hair strands collected from 2057 human male and female volunteers, from 23 regions of the world and (ii) the correlation between visual assessments and colorimetric measurements.

METHODS

Hair strands were analysed by a spectrocolorimeter under the L*, a*, b* referential system and scored in vivo by experts before sampling, through standardized visual reference scales based on a 1-10 range.

RESULTS

Results show that from a typological aspect, black or dark brown hairs largely predominate among studied ethnic groups, whereas Caucasian or derived populations exhibit the widest palette of medium to fair shades, partly explaining some past interbreeding among populations. Instrumental measurements clearly confirm that a given colour of a pigmented hair, at the exclusion of red hairs, is mostly governed by two components, L* and b*, from the L*, a*, b* reference system.

CONCLUSION

The comparisons between visual assessments and instrumental data show that these appear closely linked. Darker hairs show close or subtle variations in L*, a*, b* parameters, making their individual colour differentiation calling for technical improvements in colorimetric measurements. The latter are likely governed by other physical factors such as shape, diameter and shine.

A functional Sp1/Egr1-tandem repeat polymorphism in the 5-lipoxygenase gene is not associated with myocardial infarction

Arachidonate 5-lipoxygenase is an enzyme encoded by the ALOX5 gene, and plays an important role in the synthesis of leukotrienes. These are inflammatory mediators, and have been involved in atherosclerosis and other pathological processes that require proinflammatory activities. Human and animal studies have suggested a role for the ALOX5 gene in atherosclerosis, including a significant association between a promoter polymorphism and a carotid intimal-medial thickness in response to dietary fat. This polymorphism was three- to six-tandem repeats of a Sp1/Egr1 binding motif (GGGCGG)(n), and the number of repeats has been linked with the amount of gene expression. We hypothesized that this ALOX5 polymorphism could influence the risk for myocardial infarction (MI). First, we analysed the effect of the four alleles on gene expression by transfecting the HEK-293 cell line with luciferase reporter-constructs. We found that luciferase activities are dependent on the number of the Sp1/Egr1 repeats, with the three and six repeats having the lowest and highest values. We genotyped 312 male MI survivors, aged < 55 years, and 376 healthy controls matched with patients for sex, age, and ethnicity. Ninety-six per cent of the patients were smokers, compared to only 42% among the controls (P < 0.001; OR = 31.84). The 55 + 56 repeat genotypes were less frequent in patients (55 = 56%, 56 = 0.6%) compared to controls (55 = 60%, 56 = 3%). However, these were non-significantly different frequencies. In addition, no difference in MI-onset age and biochemical values was found between the allele and genotypes. In conclusion, we confirmed the effect of the ALOX5-promoter polymorphism on gene expression, but our data did not support a significant effect of this functional variation on MI risk.

The Pro279Leu variant in the transcription factor MEF2A is associated with myocardial infarction

BACKGROUND

A myocyte enhancer factor 2A (MEF2A) mutation that segregated with coronary artery disease/myocardial infarction (CAD/MI) in a large family has recently been described. Missense mutations in sporadic coronary artery disease patients were also reported. These data suggest that mutations in exons 7 and 11 of MEF2A cause CAD/MI, though the association was refuted by another study.

OBJECTIVE

To analyse the genetic variation of exons 7 and 11 in a large cohort of Spanish CAD/MI patients and controls.

METHODS AND RESULTS

A rare polymorphism, P279L, was detected both in patients and controls. Carriers of the 279Leu allele had a threefold risk of suffering CAD/MI compared with controls (p = 0.009; odds ratio = 3.06 (95% confidence interval, 1.17 to 8.06)). In the controls the allele was found only in those under 50 years of age. Exon 11 showed a high degree of heterogeneity caused by a polyglutamine (CAG)n polymorphism, but no significant differences in genotype or allelic frequencies were found.

CONCLUSIONS

The 279Leu allele appears to be a genetic risk factor for CAD/MI in the population studied. This effect could be the result of a reduced transcriptional activity on MEF2A with 279Leu.

Expression and inheritance of hypersensitive resistance to rice hoja blanca virus mediated by the viral nucleocapsid protein gene in transgenic rice

Rice hoja blanca virus (RHBV) is a major virus disease of economic importance affecting rice in northern South America, Central America and the Caribbean. This is the first report of transgenic resistance to RHBV and the transformation of an indica rice variety from Latin America. Rice transformed with the RHBV nucleocapsid protein ( N) gene had a significant reduction in disease development. Several reactions were observed that ranged from susceptible to completely resistant plants (immunity). The resistant reactions were characterized by the production of local lesions like a hypersensitive reaction or a recovery phenotype with the emergence of symptom-less new leaves. These transgenic RHBV-resistant rice lines expressed the N gene RNA at low levels that were below the detection limit by Northern blots and only resolved by RT-PCR. The nucleocapsid protein could not be detected in any of the transgenic plants either by Western or ELISA tests. These results suggest that the resistance encoded by the N gene in these plants appears to be mediated by RNA. When challenged with RHBV, the resistant transgenic lines showed a significant increased performance for important agronomic traits including the number of tillers, the number of grains per plant and the yield as compared to the susceptible control. Furthermore, upon inoculation some of the most-resistant transgenic lines showed agronomic traits similar to the uninoculated non-transgenic Cica 8 control. Using both agronomic traits and disease severity as criteria, several of the most-resistant lines were followed through the R(4) generation and demonstrated that the N gene and RHBV resistance was inherited in a stable manner. These transgenic rice lines could become a new genetic resource in developing RHBV-resistant cultivars.

[Therapeutic use of Cannibis Sativa L. in Arab medicine]

Arab scientists were various centuries ahead of our current knowledge of the curative power of hemp (Cannabis sativa L., Cannabaceae). Modern scientific literature ignores their contribution on the subject. We review in this paper the therapeutic uses of the plant in Arabic medicine from the 8th to the 18th century. Arab physicians knew and used its diuretic, anti-emetic, anti-epileptic, anti-inflammatory, pain-killing and antipyretic properties, among others.

Impact of biventricular pacing on mortality in a randomized crossover study of patients with heart failure and ventricular arrhythmias

Biventricular (BV) pacing is under clinical investigation for the treatment of heart failure. Its impact on mortality is unknown. Patients with heart failure and ventricular tachyarrhythmias received an implantable cardioverter defibrillator with BV pacing capability. Patients were randomized 1:1 to BV pacing or no pacing, then crossed over to the alternate mode after 3 months. All-cause mortality was measured in each arm up to the point of crossover. Fifteen of 222 patients died between implant and crossover. Five patients died while programmed to BV pacing and 19 died while programmed to no pacing. Survival in the BV pacing arm was 93 +/- 4% versus 86 +/- 6% in the no pacing arm (P = 0.18). In a patient population with symptomatic heart failure and ventricular arrhythmias, BV pacing does not appear to be associated with excess mortality. Larger and longer studies will be needed to determine if BV pacing confers a survival benefit.

Performance of a new steroid-eluting coronary sinus lead designed for left ventricular pacing

The Ventak CHF/CONTAK CD Biventricular Pacing Study is a prospective randomized trial to examine the safety and efficacy of biventricular (BV) pacing in patients with standard indications for an ICD, symptomatic heart failure, a LVEF < or = 0.35, and a QRS > or = 120 ms. Patients underwent implantation of a BV pacing and sensing system with backup defibrillation capability, which includes a steroid-eluting coronary venous lead that is advanced into the coronary venous vasculature by over-the-wire techniques. LV pacing threshold, BV impedance, and BV R wave amplitude were measured in 58 consecutive patients. Using a percutaneous over-the-wire insertion technique, steroid-eluting coronary venous leads were associated with satisfactory mean LV pacing threshold, BV impedance, and BV R wave amplitude acutely up to 4 months after implantation. Pacing threshold stabilized 2 weeks after lead implantation and sensing threshold remained stable from the time of implant.

Efficacy of biventricular sensing and treatment of ventricular arrhythmias

While much is known concerning the hemodynamic effects of biventricular (BV) pacing, little has been reported concerning the efficacy of BV sensing and pacing in the detection and treatment of ventricular tachyarrhythmias. Two hundred nineteen heart failure (HF) patients with VT or VF and a QRS > or = 120 ms during sinus rhythm received an ICD capable of BV pacing and sensing. Detection times of induced VF and success rates for terminating induced VT were measured. The ICD system used a left ventricular epicardial lead implanted via thoracotomy (52 patients) or a specially designed percutaneous, over-the-wire lead inserted in the coronary venous system. VF detection times and VT termination rates by antitachycardia pacing (ATP) were compared with those measured in a population of recipients of ICD using a RV lead alone. Median induced VF detection times were comparable (2.0-s BV vs 1.8-s RV). Termination of induced VT on the first attempt was comparable with BV pacing (87.4%) versus RV pacing (89.6%). The time to detect induced VF was not different with ICDs using BV sensing versus conventional ICDs using RV sensing alone. Similarly, the rates of successful termination of induced VT by ATP with BV or RV pacing were comparable.

Ambulatory system to aid in decision making and risk stratification in postinfarction patients

Knowledge of the clinical and electrophysiological features of certain cardiovascular risk groups, the adaptation and specialization of clinical protocols, the availability of tools to make determinations for use in patient follow-up and to assess the efficacy of the treatments applied, and the proper processing of different parameters can aid in decision making, leading to the application of a given therapeutic approach, and can facilitate the performance of group and multicenter studies. To address these needs, a simple, low-cost, portable ECG processing system has been designed that complements the current techniques for managing patients with ischemic heart disease and nonmalignant ventricular arrhythmias. This system, consisting of an electrocardiograph and a laptop PC, determines the following parameters on the basis of the ECG: incidence of arrhythmia, heart rate variability, QT dispersion, ECG criteria for ventricular hypertrophy and late potentials. Left ventricular ejection fraction and diastolic function (according to Doppler ultrasound) and other basic epidemiological parameters are typed in. Moreover, the system integrates these parameters, which have usually been considered separately, to arrive at second-level indicators with a greater predictive capacity during the long-term follow-up of patients with ischemic heart disease and ventricular arrhythmias, thus providing an idea of the risk of mortality and the onset of arrhythmic events and allowing risk stratification in this patient population. Finally, the system includes a database of all the patients analyzed, with tools that make it possible to follow the course of their disease and to assess the efficacy of the treatments applied.

[A comparison of clinical and angiographic outcome after implantation of a Wiktor stent in large and small coronary arteries]

The objective of this study was to investigate the mid term influence of vessel size in clinical and angiographic outcome, after Wiktor stent implantation in arteries larger and smaller than 3 mm.

METHOD

A total of 188 stents were implanted in 167 patients divided in two groups. Group 1: stents implanted in arteries smaller than 3 mm, 40 stents in 38 patients. Group 2: in arteries larger than 3 mm. 148 stents in 129 patients. Clinical follow up and a repeated coronary angiographic study were carried out after six months.

RESULTS

Angiographic success was achieved in 97% and 98% cases, with clinical success in 92% and 95% respectively. Acute occlusion occurred in 2 patients of group 1 (5%), and in four patients in group 2 (2.7%); one patient died and four patients suffered a non-fatal myocardial infarction. During clinical follow up, nine patients presented a major complication, two in group 1 and seven in group 2 (5.5% vs. 5.6%). Asymptomatic survival was 86% and 84% respectively. In angiographic follow up we observed a restenosis rate of 41% of the patients in group 1 and 25% of those in group 2. Immediate gain was similar in both groups, but late loss (1.06 +/- 0.85 vs 0.97 +/- 0.86) and loss rate (0.60 vs 0.46) were greater in group 1.

CONCLUSION

The frequency of stent thrombosis as well as the incidence of restenosis were higher in arteries smaller than 3 mm. No differences were observed in the incidence of major ischemic events.

Comparison of Colombian and Costa Rican strains of rice hoja blanca tenuivirus

The sequences of RNA-3 and RNA-4 of rice hoja blanca tenuivirus isolates from Colombia and from Costa Rica were determined and analyzed. These isolates were 98.9% and 98.6% identical in the coding and non-coding regions of RNA-3, and 96.9 and 91.5% identical in the coding and non-coding regions of RNA-4, and are therefore strains of the same virus. There is about three times as much variation between isolates (based on consensus sequences) as there is within isolates (based on sequences of individual clones). There is also considerably more variation for RNA-4 (both between and within isolates) than there is for RNA-3, even though between tenivirus species RNA-3 has diverged more than RNA-4, implying that the evolution of the tenuivirus RNAs is not necessarily dependent on the amount of variation found for these RNAs.

Mitral valve replacement in a heart transplant recipient with iatrogenic mitral regurgitation

A 65-year-old cardiac transplant recipient suffered rupture of the mitral valve apparatus during endomyocardial biopsy of the left ventricle. Severe mitral regurgitation resulted, and because of heart failure with progressive clinical deterioration the patient was finally subjected to mitral valve replacement. He had a favorable postoperative course and is now asymptomatic.

Detection of Dekkera-Brettanomyces strains in sherry by a nested PCR method

Brettanomyces sp. and its ascosporogenous sexual state, Dekkera sp., have been well documented as spoilage microorganisms, usually associated with barrel-aged red wines. In this report, we describe the genetic characterization, on the basis of DNA content per cell, electrophoretic karyotyping, and mitochondrial DNA restriction patterns, of a Dekkera yeast strain isolated from sherries and of a number of other Brettanomyces and Dekkera strains. By using a genomic DNA fragment of the isolated Dekkera strain, we developed a two-step PCR method which directs the specific amplification of target DNA from this strain and from other Brettanomyces-Dekkera strains. The method efficiently amplified the target DNA from intact cells, obviating DNA isolation, and yielded a detection limit of fewer than 10 yeast cells in contaminated samples of sherry.

[Clinical usefulness of stored electrograms in implantable defibrillators]

BACKGROUND AND PURPOSE

The storage of intracavitary electrograms by the automatic implantable defibrillators is one of the latest advantages. The objective of this study was to determine the clinical utility and limitations of electrograms stored by the new generation of defibrillators.

MATERIAL AND METHODS

We have implanted at our institution 43 generators with the facility of storing electrograms; 8 Ventak P2, 17 PRxII, and 1 PRxIII from CPI, 14 Jewel, from Medtronic and 3 Guardian ATP 4215, from Telectronics. All were implanted with an endocavitary system lead, an only one patient needed a subcutaneous patch. Mean age was 57 +/- 16 years, 36 were males and 7 women. The mean left ventricular ejection fraction was 44 +/- 23%. The mean follow up was 6 +/- 8 months (limits 1-20 months).

RESULTS

We registered and analyzed a total of 268 episodes in 20 patients. Fourteen (82%) received what was considered appropriate therapy. Three patients (from 17 with any treatment delivered by the defibrillator) presented an inappropriate therapy. The parameters, "onset" and "stability", were differentiated in each arrhythmia, the "onset" is useful to differentiate sinus tachycardia, but not atrial fibrillation, from ventricular tachycardia. Programming a stability value between 30-40 mseg eliminates 88% of inappropriate therapies due to atrial fibrillation. In all patients, the identification of the event, facilitated by the stored electrograms, allowed us to resolve the problem.

CONCLUSIONS

The programmable features "onset" and "stability" allowed us to eliminate a significant number of inappropriate therapies. The stored electrograms facilitate the identification of the events, leading to treatment by the generator, and were very useful in guiding the clinical management of the patient.

[Cervical synovial sarcoma: a case report]

Synovial sarcomas of the head and neck are rare, fewer than 80 cases having been reported in the literature. A synovial sarcoma of cervical soft tissues presented as a lateral mass in a 51-year-old male and was treated by cervical dissection and radiotherapy. After 24 months the patient is recurrence-free. The histology and origin of synovial sarcomas is discussed.

Complete nucleotide sequence and coding strategy of rice hoja blanca virus RNA4

The complete sequence of rice hoja blanca virus (RHBV) RNA4 has been determined, based on the sequence of the corresponding cDNA clones. RNA4 consists of 1991 nucleotides with two open reading frames (ORFs). One putative ORF is located in the 5'-proximal region of the viral RNA4; it encodes a protein of predicted M(r) 20076 which corresponds to the major non-structural protein that accumulates in RHBV-infected rice plants, and which bears limited sequence identity with the helper component of tobacco vein mottling potyvirus. The other ORF is located in the 5'-proximal region of the viral complementary RNA4 and encodes a protein of predicted M(r) 32,469. Between the two ORFs is an intergenic region of 524 nucleotides, part of which can theoretically adopt a stable stem-loop structure; the 5' and 3' ends can potentially base-pair over 16 nucleotides, producing a pan-handle configuration. These characteristics are in favour of an ambisense coding strategy for RHBV RNA4.

[Lupus induced by quinidine]

The case is described of a 34 year old female who suffered quinidine induced lupus, which appeared 14 months after the administration of the drug, and it was necessary to substitute it. This secondary effect o quinidine, which is rarely described, can go unnoticed if it is no kept in mind. The diagnostic criteria for drug induced lupus ar discussed and the clinical and analytical manifestations of 27 cases o quinidine induced lupus described in the literature are reviewed.