Explanatory model of symptoms of stress, anxiety and depression in the general population: Cross-sectional study during the COVID-19 pandemic

COVID-19 pandemic has had a great impact worldwide, specially affecting mental health and has undoubtedly taken part in human behaviour modification, increasing global health burden and with stress, anxiety and depression being the main contributors to this load. Because of the importance of this issue, the objective of this study was the creation of an explanatory model for the causal relationship of the main psychological variables: stress, anxiety and depression in the COVID-19 pandemic context. A cross-sectional study was carried out with a sample of 709 volunteers, sociodemographic variables and psychological symptoms were measured through a virtual DASS-21 questionnaire, during the COVID-19 pandemic, dated from November 2 to 6, 2020. A structural equation model using the weighted least squares means and the adjusted variance was employed for the creation and adjustment of the explanatory relational model. The results showed the presence of stress, anxiety and depression symptoms among the general population. The model showed an adequate fit (CFI = 0.94; TLI = 0.94; RMSEA = 0.06; P = 0.000) and was able to explain more than 80% of depressive symptoms (R²  = 0.86) and more than 70% of anxiety symptoms (R²  = 0.72), in addition to showing a unidirectional causal relationship of long-term stress on anxiety, and anxiety on depressive symptoms, showing a linked behaviour of the same, in the adjusted model. It was also outlined that this model was characterized by being expressed mainly in women, with lower quality of sleep and at a younger age.

The Eya1 Phosphatase Mediates Shh-Driven Symmetric Cell Division of Cerebellar Granule Cell Precursors

During neural development, stem and precursor cells can divide either symmetrically or asymmetrically. The transition between symmetric and asymmetric cell divisions is a major determinant of precursor cell expansion and neural differentiation, but the underlying mechanisms that regulate this transition are not well understood. Here, we identify the Sonic hedgehog (Shh) pathway as a critical determinant regulating the mode of division of cerebellar granule cell precursors (GCPs). Using partial gain and loss of function mutations within the Shh pathway, we show that pathway activation determines spindle orientation of GCPs, and that mitotic spindle orientation correlates with the mode of division. Mechanistically, we show that the phosphatase Eya1 is essential for implementing Shh-dependent GCP spindle orientation. We identify atypical protein kinase C (aPKC) as a direct target of Eya1 activity and show that Eya1 dephosphorylates a critical threonine (T410) in the activation loop. Thus, Eya1 inactivates aPKC, resulting in reduced phosphorylation of Numb and other components that regulate the mode of division. This Eya1-dependent cascade is critical in linking spindle orientation, cell cycle exit and terminal differentiation. Together these findings demonstrate that a Shh-Eya1 regulatory axis selectively promotes symmetric cell divisions during cerebellar development by coordinating spindle orientation and cell fate determinants.

Exercise and cancer: a position statement from the Spanish Society of Medical Oncology

Due to improvements in the number of cancer survivors and survival time, there is a growing interest in healthy behaviors, such as physical activity (PA), and their potential impact on cancer- and non-cancer-related morbidity in individuals with cancer. Commissioned by the Spanish Society of Medical Oncology (SEOM), in this review, we sought to distill the most recent evidence on this topic, focusing on the mechanisms that underpin the effects of PA on cancer, the role of PA in cancer prevention and in the prognosis of cancer and practical recommendations for clinicians regarding PA counseling. Despite the available information, the introduction of exercise programs into the global management of cancer patients remains a challenge with several areas of uncertainty. Among others, the most effective behavioral interventions to achieve long-term changes in a patient’s lifestyle and the optimal intensity and duration of PA should be defined with more precision in future studies.

Jumping performance differences among elite professional handball players with or without previous ACL reconstruction

AIM

Handball is one of the most challenging sports for the knee joint. Persistent strength and jumping capacity alterations may be observed among athletes who have suffered anterior cruciate ligament (ACL) injury. The aim of this study was to examine unilateral and bilateral jumping ability differences between previously ACL-reconstructed rehabilitated elite handball athletes and sex, age and uninjured sport activity level-pairs of control players.

METHODS

It was a Cross-sectional study with one factor: previous ACL injury. We recruited 22 male (6 ACL-reconstructed and 16 uninjured control players) and 21 female (6 ACL-reconstructed and 15 uninjured control players) elite handball players who were evaluated 6.2±3.4 years after surgical ACL reconstruction. A battery of jump tests, including both bilateral and unilateral maneuvers, was performed. Two-tailed unpaired (intergroup comparison) and paired (intragroup comparison) t-tests were performed for mean comparisons. The P-value cut-off for significance was set at <0.05.

RESULTS

The previously ACL-reconstructed female athletes showed a lower bilateral drop jump contact time (0.429±179.9 vs. 0.349±151 s, P<0.05) and less distance reached (3.820±0.54 vs. 4.428±0.44 m, P<0.05) in the unilateral triple hop for distance (UTHD) on their reconstructed leg compared with the dominant legs of the uninjured control athletes. No significant differences were observed for any other recorded variable. Among the male athletes, no significant differences between groups were found for the studied jumping variables.

CONCLUSION

Previously ACL-reconstructed elite female handball athletes demonstrated both lower vertical bilateral drop jump (VBDJ) contact times and lower UTHD scores for the injured leg several years after injury. These deficits could contribute to an increase in ACL re-injury risk.

Unresponsiveness to a kidney graft after a fully matched allogenic bone marrow transplantation combined with low-dose tacrolimus therapy: a case report

We present the case of a patient with past medical history of acute mieloblastic leukemia treated with a related, fully match alogenic bone marrow transplantation (BMT). He presented after BMT treatment graft versus host disease (GVHD) and thrombotic thrombocytopenic purpura. He also developed end-stage renal disease that required renal replacement therapy. A preemptive kidney transplant was performed. The haematopoiesis were in complete chimera and the patient developed tolerance to the kidney graft, requiring only minimal immunossupression because of his GVHD.

Numb links extracellular cues to intracellular polarity machinery to promote chemotaxis

Cell polarization is essential throughout development for proliferation, migration, and differentiation. However, it is not known how extracellular cues correctly orient cell polarity at distinct stages of development. Here, we show that the endocytic adaptor protein Numb, previously characterized for its role in cell proliferation, subsequently plays an important role in cell migration. In neural precursors stimulated with the chemotactic factor BDNF, Numb binds to activated TrkB, the BDNF receptor, and functions both as an endocytic regulator for TrkB and as a scaffold for aPKC (aPKC). Thus, Numb promotes BDNF-dependent aPKC activation. Interestingly, Numb is also a substrate of aPKC. When phosphorylated, Numb exhibits increased efficacy in binding TrkB and in promoting a chemotactic response to BDNF. Therefore, Numb functions in a feed-forward loop to promote chemotaxis of neural precursors, linking BDNF, an extracellular cue, to aPKC, a critical component of the intrinsic polarity machinery.

Role of chemoradiotherapy alone in the management of unfit patients with nonmetastatic locally advanced squamous cell carcinoma of the esophagus

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Background: Surgery is considered the best treatment for patients (pts) with non-metastatic locally advanced squamous cell carcinoma of the esophagus who have responded to neoadjuvant chemoradiotherapy (CRT) in terms of locoregional control. However, in these pts PFS and OS have not been proved superior to those achieved by CRT alone. Besides, the addition of surgery to CRT increases treatment-related morbidity and mortality. Unfit pts are usually declined for surgical procedures and included in definitive CRT programs. The aim of this study was to define the role of non-surgical strategies (CRT, CT or RT) in unfit pts considered non-optimal for surgical procedures.

Methods: We retrospectively reviewed 90 pts with squamous cell carcinoma of the esophagus who had been diagnosed and treated at our institution from January 2004 to December 2009. Fifty-one pts were non-metastatic among which 19 underwent surgery and 32 a non-surgical procedure (CRT, CT, RT or BSC). Our aim was to identify OS, PFS, RR, data on comorbidity and toxicity in these 32 pts.

Results: Thirty out of the 32 pts were men with a median age of 62 years (range 41-90). Comorbidity was detected in 17 pts (53%) as means of respiratory disorders (21.9%), cardiopathy (12.5%), hepatopathy (21.9%), synchronic tumors (25%) and metachronic tumors (25%). Seventeen pts received CRT, 7 received CT, 1 received RT and 7 received BSC alone (53%, 22%, 3% and 22% respectively). Grade 3 and 4 toxicities were observed in 15 pts (46.9%) as means of mucositis (18.8%), oesophagitis (15.6%), diarrhoea (12.5%) and neutropaenia (12.5%). One patient in the CRT group died of toxicity. RR was 43.8% (70.6% for CRT, 14.3% for CT alone). Median follow-up was 17.2 months. Median PFS was 11.3 ± 6.12 months (17.9 for CRT, 5.1 for CT alone). Median OS was 15.6 ± 7.6 months (6.9 for CT alone).

Conclusions: Our experience with CRT alone in unfit pts with locally advanced squamous cell carcinoma of the oesophagus supports its use with a median PFS of 17.9 months and controllable toxicity. Data on median OS are lacking due to pending long-term follow-up.

No significant financial relationships to disclose.

Comparison of imiquimod 5% cream versus radiotherapy as treatment for eyelid basal cell carcinoma

BACKGROUND

To compare the efficacy, cosmesis and tolerance of two non-surgical treatments-imiquimod (IMQ) 5% cream and radiotherapy (RT)-to combat periocular nodular basal cell carcinoma (BCC).

METHODS

Twenty-seven patients with clinical and histopathological diagnosis of nodular BCC on the eyelid were included and randomly selected: 15 patients were treated with IMQ 5% cream once daily, 5 days/week for 6 weeks, and 12 patients were treated with RT.

RESULTS

All tumours showed histopathological remission within 3 months of the treatment, and sustained clinical remission was documented in each patient after 24 months' follow-up. Treatment tolerability was rated as moderate with IMQ and good with RT. Functional results were better in patients treated with IMQ. Loss of eyelashes was reported for most of the patients treated with RT.

CONCLUSIONS

IMQ and RT therapies are effective for treating eyelid nodular BCCs. Cosmesis and functional results were better with IMQ, while tolerability was higher with RT.

Comparison of an interferon-gamma assay with tuberculin skin testing for detection of tuberculosis (TB) infection in patients with rheumatoid arthritis in a TB-endemic population

OBJECTIVE

Tuberculosis (TB) in patients with rheumatoid arthritis (RA) undergoing treatment with anti-tumor necrosis factor (TNF) agents is commonly the result of reactivation of latent TB infection (LTBI); detection and treatment of LTBI is essential before treatment with anti-TNF agents. We reported previously that the tuberculin skin test (TST) is inaccurate for diagnosis of LTBI in patients with RA. Here, we compare the prevalence of LTBI in RA patients and matched controls according to positive TST and QuantiFeron-TB Gold In-Tube version (QFT) results and determine their agreement.

METHODS

A cross-sectional study of 101 RA patients and 93 controls was conducted in Lima, Perú, where the prevalence of LTBI in the general population has been estimated to be 68%. Blood was drawn for QFT assay followed by TST using 2-TU of RT 23 purified protein derivative. TST was deemed positive at >or= 5 mm for RA patients and >or= 10 mm for controls.

RESULTS

There were no significant differences between RA patients and controls for age, sex, bacillus Calmette-Guérin vaccination, or history of or contact with TB. 88% of patients had active RA disease and 2 (1.9%) patients had indeterminate QFT results. The number of subjects testing positive with the QuantiFeron assay was comparable between patients and controls (44.6% vs 59.1%, respectively), whereas the TST detected significantly less LTBI among RA patients (26.7%) than controls (65.6%). Thus, the rate of LTBI in RA patients represented 75% and 41% of the rate in their controls using QFT or TST, respectively (p = 0.008). Poor agreement between TST and QFT was seen in RA patients, but in controls, good agreement was observed between these tests.

CONCLUSION

In a TB-endemic population, the QuantiFeron-TB Gold In-Tube assay seemed to be a more accurate test for detection of LTBI in RA patients compared with the TST, and may potentially improve the targeting of prophylactic therapy before treatment with anti-TNF agents.

The role of a mentoring group for family therapy trainees and therapists of color

This article discusses the development, process, and impact of a mentoring group for family therapists of color. A within-group process for trainees of color in a predominantly White institution can provide a valuable resource for support, validation, empowerment, and collective action. The article examines how such mentoring promotes the effectiveness of therapists of color, as well as the practices and goals of social justice and diversity within training institutions and the field in general. Reflections and recommendations for implementing such a group are offered, as well as a personal narrative of a group member's experience of finding her voice in the group.

Dendritic cell immunizations alone or combined with low doses of interleukin-2 induce specific immune responses in melanoma patients

Dendritic cell (DC)-based therapy has proved to be effective in patients with a variety of malignancies. However, an optimal immunization protocol using DCs and the best means for delivering antigens has not yet been described. In this study, 20 patients with malignant melanoma in stages III or IV were vaccinated with autologous DCs pulsed with a melanoma cell lysate, alone (n = 13) or in combination with low doses of subcutaneous (s.c.) interleukin (IL)-2 injections (n = 7), to assess toxicity, immunological and clinical responses. Monocyte-derived DCs were morphological, phenotypic and functionally characterized in vitro. Peripheral blood mononuclear cells (PBMC), harvested from patients either prior to and after the treatment, were analysed using enzyme-linked immunosorbent spot (ELISPOT). After vaccination, 50% of the patients tested (seven of 13) from the first group and (three of seven) from the second, showed an increase in interferon (IFN)-gamma production in response to allogeneic melanoma cell lines but not to controls. Four of five tested human leucocyte antigen (HLA)-A2(+) patients with anti-melanoma activity also showed specific T cell responses against peptides derived from melanoma-associated antigens. Delayed type IV hypersensitivity reaction (DTH) against melanoma cell lysate was observed in six of 13 patients from the group treated with DC vaccines only and four of seven from the group treated with the combination of DCs and IL-2. Significant correlations were found between DTH-positive responses against tumour lysate and both disease stability and post-vaccination survival on the stage IV patients. There were no toxicities associated with the vaccines or evidence of autoimmunity including vitiligo. Furthermore, no significant enhancement was observed as a result of combining DC vaccination with IL-2. Our data suggest that autologous DCs pulsed with tumour lysate may provide a standardized and widely applicable source of melanoma specific antigens for clinical use. It is safe and causes no significant side effects and has been demonstrated to be partially efficient at triggering effective anti-melanoma immunity.

Attenuated response to purified protein derivative in patients with rheumatoid arthritis: study in a population with a high prevalence of tuberculosis

BACKGROUND

The purified protein derivative (PPD) skin test is the only widely used method which detects latent tuberculosis infection (LTBI) and is dependent on a normal T cell function. In rheumatoid arthritis (RA) the T cell function is altered, which may result in an inability to develop an adequate PPD reaction.

OBJECTIVES

To evaluate the response to PPD in patients with RA and to compare it with that of control subjects.

METHODS

112 patients with RA and 96 healthy controls were studied. PPD 5 U was applied using the Mantoux method, and skin reaction was measured at 72 hours. The reaction was considered negative for PPD <5 mm.

RESULTS

There were no significant differences in age, sex, history of bacille Calmette-Guerin vaccination, or tuberculosis contact between the two groups. The median size of the PPD induration in the patients with RA was significantly less than that in the control group (4.5 v 11.5 mm, p<0.01). 79 (70.6%) patients with RA compared with 25 (26%) of the control group had a negative reaction to PPD (p<0.01), a response not influenced by disease activity or duration of disease in the patients with RA.

CONCLUSION

A PPD skin test is not an appropriate test for recognising LTBI in patients with RA in our population.

[Evaluation of a pharmaceutical care program to improve adherence to antiretroviral therapy]

OBJECTIVE

To establish the impact of a pharmaceutical care program on the improvement of adherence to antiretroviral therapy, and on patient immunologic and virologic outcome.

MATERIALS AND METHODS

A multicenter, observational, prospective study in a HIV-infected patient cohort under treatment with antiretrovirals selected by random sampling in 19 Spanish hospitals. The study lasted 12 months, in which the program was applied through a baseline preprocedural visit and 4 quarterly visits. Adherence estimation was based on pill counting. An adherence > or = 90, or > or = 95% was considered adequate (in two time points).

RESULTS

541 patients were included, most of them were males (68.8%) between 20 and 78 years of age. Major risk groups included injecting drug users (43.4%) and heterosexuals (29.4%). Sixty percent had already received treatment for more than 3 years. Mean baseline viral load and CD4 count values were 32,866 copies/ml and 485 cells/mm3, respectively. Throughout the study a slight increase in the percentage of adherent patients was seen; however, statistical significance was not reached (64.3 and 79.2% of patients showed an adherence > 95 and > 90%, respectively, during the fourth quarter, versus 59.8 and 75.5% at baseline). A statistically significant decrease in viral load and increase in CD4 cells was seen following program application. The percentage of patients with a viral load < 200 copies/ml was 72.2, 76.7, and 75.0% at the 2nd, 3rd, and 4th quarters, respectively, versus 64.2% at baseline. CD4 cell counts increased by 50 cells/mm3 on average from the start to the end of follow-up.

CONCLUSIONS

Patients included in the program had a good immunologic and virologic outcome, and a trend towards an increased percentage of patients with good adherence was also seen. These results confirm the need to implement follow-up programs for patients receiving antiretrovirals in order to ensure maximum therapeutic benefits.

[The state of poisoning in Navarra]

We briefly comment on the state of clinical toxicology in Navarra and in the rest of Spain, with reference to the Toxicology Committee of Navarra and its aims. Epidemiological data from the Emergency Service of the Hospital of Navarra is presented, as well as where to find information on the subject; the epidemiological registration sheet designed by the SEMESTOX group is attached. A description is given of the characteristics of therapeutic drugs and drugs of abuse determination (type of sample, methodology and interpretation of results) carried out in the toxicological analytical unit of the Hospital of Navarra. Finally, reference is made to all of the antidotes available to the Pharmacy Service of the Hospital of Navarra, which is the reference center for the whole of the autonomous community of Navarra. A description is given for each medicine including its indications.

Endobronchial hamartoma

OBJECTIVES

To describe clinical, endoscopic, radiographic, and follow-up characteristics of a series of patients in whom endobronchial hamartoma (EH) had been diagnosed.

METHODS

Retrospective study of all cases of hamartoma diagnosed by bronchial biopsy between 1974 and 1997 in a tertiary referral hospital in Madrid, Spain.

RESULTS

EH was diagnosed 47 patients during the study period. Four patients were excluded from the study because no clinical history was available. We analyzed the cases of 43 patients (37 men and 6 women), with a mean (+/- SD) age of 62 +/- 12 years. Seven patients had a concurrent lung neoplasm, and the EH was an incidental endoscopic finding. Among the other 36 patients, 31 had a new onset of respiratory symptoms, most commonly, recurrent respiratory infections in 16 patients (44%) and hemoptysis in a further 12 patients (33.4%). Chest radiograph findings were abnormal in 38 of 43 patients. At bronchoscopy, the lesions were equally distributed throughout the right and left lungs with no clear lobar predilection. Endobronchial obstruction was evident in 26 patients (72.2%) without concurrent neoplasm, 17 of whom underwent resection with a rigid bronchoscope and laser, with total resolution in 13 patients. Partial resolution was achieved in four patients, two of whom needed a second endoscopic procedure. Five patients were treated with open lung surgery. Clinical and endoscopic follow-up was performed in 23 patients at 1 to 73 months (mean, 17 months), and recurrence was found in 4 patients.

CONCLUSION

EH frequently produces respiratory complaints and radiographic abnormalities. Patients with endobronchial obstructions had satisfactory responses to endoscopic therapy.

The complete normalization of the adrenocortical function as the criterion of cure after transsphenoidal surgery for Cushing's disease

Transsphenoidal microsurgery is the standard treatment for patients with Cushing's disease. However, there is general lack of agreement regarding the definition of cure. We studied 58 patients with corrected hypercortisolism after transsphenoidal surgery for Cushing's disease. Plasma and urinary cortisol levels were measured after surgery. After the postsurgical hypocortisolism stage (or periodically in patients without hypocortisolism), urinary free cortisol, plasma cortisol at 0800 h and 2300 h, morning cortisol after 1 mg dexamethasone, and cortisol response to insulin-induced hypoglycemia were performed. Patients were classified in 3 groups: group I, patients with transient hypocortisolism and normal hypothalamus-pituitary-adrenal axis afterwards; group II, patients with transient hypocortisolism and abnormalities in the circadian rhythm or the stress response afterwards; and group III, patients without postoperative hypocortisolism. Thirty-three patients were included in group I, 8 in group II, and 17 in group III. Groups I and II were similar in postsurgical plasma cortisol (46.9 +/- 30.3 vs. 60.7 +/- 38.6 nM) and mean follow-up (69.8 vs. 68.8 months) but were significantly different in their recurrence rate (3.4% vs. 50%, P < 0.001). Patients in group III had normal postsurgical plasma and urinary cortisol but persistent abnormalities in circadian rhythm and stress response. After a mean follow-up of 39.1 months, their recurrence rate was similar to that of group II (64.7% vs. 50%). The complete normalization of the adrenocortical function, which is always preceded by postsurgical hypocortisolism, is associated with a very low recurrence risk and should be considered, in our opinion, the main criterion of surgical cure in Cushing's disease.

Remediation of DNAPL pools using dense brine barrier strategies

Although dense nonaqueous phase liquid (DNAPL) pools are an important source of groundwater contamination, little experimental data have been generated to develop a mature level of understanding of the problem, and few strategies specifically aimed at remediation have been advanced. We discuss the dominant importance of these features in subsurface systems, present novel two- and three-dimensional heterogeneous experimental systems, and show results from two evolving strategies for remediating DNAPL pools. These strategies involve the joint use of a dense brine barrier and controlled mobilization of trapped DNAPL using small-volume surfactant flushes. These experiments demonstrate a controlled, substantial reduction of entrapped DNAPL in both two- and three-dimensional heterogeneous domains, using less than a single pore volume of flushing solution in some cases.

[Endoscopic coagulation with argon plasma, a therapeutic option in gastric antral vascular ectasia]

BACKGROUND

Gastric Antral Vascular Ectasia or Watermelon stomach is a rare cause of chronic gastrointestinal bleeding, often presenting as a chronic iron deficiency anemia. This condition can be associated with some other diseases such as cirrhosis, autoimmune diseases and others. We report two patients treated with Argon Plasma Coagulation, a 68 years old male with an ethanol related cirrhosis and a 72 years old female with an idiopathic Gastric Antral Vascular Ectasia. The characteristic endoscopic features were mistaken for many years as gastritis. Both patients presented with severe anemia requiring multiple transfusions as treatment. Due to the poor operative risk, both patients were treated with Argon Plasma Coagulation with good results.

Quantum gravity corrections to neutrino propagation

Massive spin-1/2 fields are studied in the framework of loop quantum gravity by considering a state approximating, at a length scale L much greater than Planck length l(P), a spin-1/2 field in flat spacetime. The discrete structure of spacetime at l(P) yields corrections to the field propagation at scale L. Neutrino bursts ( &pmacr; approximately 10(5) GeV) accompanying gamma ray bursts that have traveled cosmological distances L are considered. The dominant correction is helicity independent and leads to a time delay of order (&pmacr;l(P))L/c approximately 10(4) s. To next order in &pmacr;l(P), the correction has the form of the Gambini and Pullin effect for photons. A dependence L(-1)(os) approximately &pmacr;(2)l(P) is found for a two-flavor neutrino oscillation length.

[Acute poisoning with methotrexate used as an abortifacient: description of 2 cases]

Acute intoxication with methotrexate, used as an abortive, has not been described in Chile. We report two female patients, aged 15 and 24 years old, who presented with mucositis, erythrodermia, pancytopenia, and elevation of hepatic enzymes. Plasma methotrexate levels confirmed the clinical diagnosis and both patients were treated with high leucovorin doses and management of associated complications. In one patient, pregnancy continued, giving birth to a newborn with cranial, face and limb malformations. The second patient had a late rescue with leucovorin and was discharged with a persistent sensory motor neuropathy. Considering the severity of complications and that patients may deny its use, when there is reasonable clinical suspicion of methotrexate intoxication, leucovorin treatment should be started.

Colorectal cancer: morphologic variables related with carcinoembryonic antigen serum elevation (CEA)

OBJECTIVE

The purpose of this study is to identify morphologic parameters of colorectal adenocarcinoma which may be of influence in the increase of preoperatory CEA serum levels.

METHOD

This study includes 127 patients on whom colectomy was performed. Twenty-eight morphologic parameters were analyzed in each surgical specimen. Serum determinations were made by enzymatic immunoassay. A multivariate study (logistic regression analysis) was made. Independent risk factors for CEA serum elevation were Cytologic Atypia (odd ratio: 2.85) Infiltrative Growth Pattern (odd ratio: 2.91) and the presence of tumoral cell infiltration directly among adipocytes (odd ratio: 2.62). When clinical variables (age, sex, tumor location, perforation, occlusion, hepatic metastases and peritoneal carcinomatosis) were added the infiltrative growth pattern (odd ratio: 3.12) and cytologic atypia persisted as independent risk factors, together with the clinical variable Hepatic Metastases (odd ratio: 24.84).

CONCLUSION

In our series the morphologic variables Infiltrative Growth Pattern and Cytologic Atypia are independently related with CEA serum increase and are not influenced by the variable Hepatic Metastases.

Foster care: an update

OBJECTIVE

To inform child and adolescent psychiatrists about the almost 500,000 children now residing in the American foster care system. This overview surveys the pediatric, developmental, and psychiatric needs of these children.

METHOD

Child and adolescent psychiatrists, pediatricians, a child welfare researcher, a social worker, and a psychologist developed a consensus paper from their experience with child welfare and a review of the literature in their respective fields.

RESULTS

Being in foster care is a defining experience in these children's lives. They are at risk in myriad ways: for instance, being poor, having chronic health deficits, experiencing the trauma of abuse and neglect, and suffering from a gamut of emotional challenges. Evolutionary developments in foster care such as therapeutic foster homes, kinship care, and changes in Medicaid funding will continue to alter the system.

CONCLUSIONS

Foster children are a huge reservoir of unmet pediatric and psychiatric needs; research on them is spotty at best. It is hoped that child and adolescent psychiatrists will meet the challenges these youngsters present and will advocate for them.

Treatment of adolescent Blount disease by asymmetric physeal distraction

An alternative treatment is presented for late-onset Blount disease in a 14-year-old boy. The technique consists of asymmetric physeal distraction of the proximal tibial growth plate by using a modified Wagner fixator-distractor device that allows progressive angular correction. The patient had a 23 degrees varus deviation of the left tibia, and no physeal bone bridges were detected. Once the fixator was assembled, distraction started 24 h after surgery at a rate of 1.5 mm/day (2 x 0.75). Complete correction was achieved in 25 days. No osteotomy of the fibula was required. The Wagner device was removed in the outpatient clinic 10 weeks postoperatively. After a 4-year follow-up, there was no loss of correction, showing a satisfactory alignment of the operated-on lower extremity. As compared with acute conventional osteotomies, asymmetric physeal distraction entails several advantages for treatment of Blount disease such as less invasive surgery, progressive and adjustable correction taking place at the apex of the deformity, and the possibility of bone lengthening if needed. Furthermore, physeal distraction does not require a second surgical step for bonegraft harvesting or for removal of the internal fixation.

Platelet autoantibodies in patients with chronic liver disease

The thrombocytopenia in chronic liver disease (CLD) has been attributed mainly to hypersplenism, although other factors such as reduced mean life span with increased platelet turnover have also been demonstrated. Immunological abnormalities have been described in the pathogenesis and progression of CLD. In this sense, many studies have reported elevated levels of platelet associated IgG (PAIgG) in patients with CLD, and it has been suggested that PAIgG could represent true antiplatelet antibody. In this study we used a glycoprotein (GP)-specific immunoassay (MACE) to determine whether PAIgG or circulating antiplatelet antibodies, reacted against the GPIIb/IIIa or GPIb/IX complexes, in patients with CLD. Thirty-six patients with CLD of diverse etiology were studied (20 female, mean age 53 years, range 38-75 years). 23 out of 36 patients (64%) had anti-GP antibodies in MACE. Particularly, 12 had anti-GPIb, 4 anti-GPIIb/IIIa, and 7 had both types of autoantibodies. The existence of these anti-GP antibodies was not related with the blood platelet count or etiology of CLD. These data show that in patients with CLD of diverse origin, there is a high prevalence of autoantibodies reacting specifically with platelet membrane GP, which constitutes the first evidence of the specific nature of platelet-bound IgG in CLD. These findings suggest that in patients with CLD, an immune mechanism may participate in inducing or aggravating the thrombocytopenia.

Antimetastatic effect of immunization with liposome-encapsulated tumor cell-membrane proteins obtained from experimental tumors

Immunization of C57BL/6 mice with tumor-derived membrane-proteins encapsulated in sized liposomes (0.2 microgram/mouse) and composed by phosphatidylcholine or sphingomyelin, significantly reduced the mean values of spontaneous lung metastasis from both B16 (0.7 +/- 0.5 and 1.2 +/- 0.6, respectively) and 3LL (4.8 +/- 2.5 and 7.2 +/- 4.1, respectively) tumors, with respect to control (HEPES) groups (4.8 +/- 1.1 and 19.0 +/- 4.4, respectively). However, no significant antimetastatic effect was observed using free tumor-derived proteins (2 micrograms/mouse) or liposome vehicle alone. Specific humoral immune response after the vaccination was studied by flow cytometry of tumor cells incubated with a pooled sample from each group of immunized mice and FITC-conjugate antimouse immunoglobulins. The results showed that the highest number of positive tumor cells was identified using sera from immunized mice with sized liposomes encapsulating tumor-derived proteins whereas the immunization with the protein fraction in free form failed to induce this effect. In addition, an increased cytotoxicity towards 3LL and B16 tumor cells can also be observed when tumor cells were incubated with spleen effector cells plus specific immunosera. In conclusion, our results show that antitumor active vaccination, using sized liposomes as adjuvants, induces an antitumor host response and a significant inhibition of tumor progression.

[A case of neutropenia and agranulocytosis induced by clozapine. The importance of a drug surveillance program for their early detection]

Clozapine is an atypical antipsychotic drug with a very low incidence of extrapyramidal effects, used in the treatment of schizophrenic patients refractory or intolerant to classical neuroleptics. Its use is limited due to the potential risk of producing agranulocytosis in 1 to 2% of patients. Despite the severity of this complication, the Federal Drug Administration allowed its use as long as its prescription is associated to a drug surveillance program that controls regularly the white cell count of patients using the drug. Three hundred three patients (210 male) have been admitted to a clozapine drug surveillance program. Two patients had a transitory leukopenia with less than 2000 leukocytes/ml and less than 1000 neutrophyls/ml, that reverted after discontinuing the drug. One patient, whose case is described, had a severe agranulocytosis with less than 500 neutrophyls/ml that required hospital admission.

[Chronic myeloid leukemia: cytogenetic and molecular study and its relationship with the disease course]

The aim of this study was to perform a cytogenetic and molecular study in patients with chronic myelogenous leukemia and to seek a possible relation between bcr gene break points and the clinical evolution of the disease. The cytogenetic study allowed to establish the presence of Ph chromosome and the molecular study localized the break point in bcr region of chromosome 22 using the Southern technique, hybridizing with bcr fragment derived probes bcr1 and bcr2. Forty eight patients were studied, 27 male (aged 46.5 years) and 21 female (aged 56). Forty seven patients were Ph +. A rearrangement in 3' bcr region was found in 25 patients and in 5' region in 23. During the follow up period 20 patients developed a blast crisis or accelerated phase. In 11 of these the rearrangement was in region'3 and their chronic phase lasted a mean of 33.1 months; in 9 the rearrangement was in region 5' and their chronic phase lasted 44.1 months. There were no differences in event-free survival between those with rearrangement in region 3' or 5', however these was a tendency towards a longer chronic phase duration in those with 5' breaks. The lack of correlation between the location of break points and the evolution of the disease may be due to a selection of patients with a better evolution and the exclusion of those with a rapid progression to blast crisis or accelerated phase.