Adverse drug effect in the context of drug shortage: the CIRUPT prospective study from the French pharmacovigilance network

OBJECTIVES

Drug shortages are of increasing concern to worldwide public health. The consequences of drug shortages for patient safety have been little studied, especially from a pharmacovigilance point of view. In this context, the network of French pharmacovigilance centres conducted the CIRUPT study (Conséquences Iatrogènes des RUPTures de stock/iatrogenic consequences of drug shortages) based on a prospective campaign of adverse effects occurring in the context of drug shortage notifications.

METHODS

All notifications involving a shortage drug submitted to the French pharmacovigilance centres between 1 January 2020 and 30 June 2021 were collected and registered in the French national pharmacovigilance database with the standardised high level term 'product supply and availability issues' and with predefined keywords in the narrative section.

RESULTS

224 cases were included, involving mainly adverse drug reactions (ADRs) (n=131/224, 59%) and medication errors (n=51/224, 23%); 29% of the cases were serious. The most represented classes of shortage drugs were: vaccines (n=78/224, 35%); drugs for acid-related disorders (H2-receptor antagonists) (n=27/224, 12%); antineoplastic agents (n=17/224, 8%); and antiepileptics (n=15/224, 7%). In 82% of cases, the involved shortage drug was the subject of information delivered to health professionals by the National Agency for the Safety of Medicines and Health Products. Drug shortages were associated with an ADR related to replacement drugs in 59% (n=131/224) of the cases, drug inefficacy in 18% (n=41/224), and/or an aggravation of the underlying disease in 11% (n=25/224).

CONCLUSIONS

From a pharmacovigilance point of view, a large diversity of anatomical therapeutic classes is involved and the risk related to drug shortages is not limited to drugs registered on 'major therapeutic interest or essential drug' lists. Information from health agencies is not sufficient to avoid the risks, and further strategies should be developed.

Cross-reactivity among and between macrolides, lincosamides, and streptogramins: Study on the French pharmacovigilance database

BACKGROUND

Hypersensitivity reactions (HSR) are reported for the macrolides, lincosamides, and streptogramins (MLS) antibiotic family. Data about cross-reactivity among and between MLS remain scarce or controversial.

OBJECTIVES

The aim of this study was to provide an overview of hypersensitivity cross-reactions among MLSs based on data extracted from the French National Pharmacovigilance Database (FPVD).

METHODS

Cases of HSR to MLSs reported between January 1985 and December 2019 were extracted from the FPVD using standardized MedDRA queries (SMQ). Cases including an allergological test involving multiple MLSs and giving at least one positive result were included.

RESULTS

Of the 8394 cases reviewed, 149 were included. HSR mainly involved pristinamycin (n = 83; 53.2%) and spiramycin (n = 31; 19.9%). HSR to MLS was immediate in 54 cases and delayed in 94 cases. Skin tests represented the majority of the allergological tests performed (n = 728; 84.7%), followed by reintroduction tests (n = 79; 9.2%). Eighty-six cross-reactivities among MLS were identified in 62 cases (41.6%). All the 25 explorations performed for streptogramins showed cross-reactivities, but only 30/253 among macrolides (11.9%). Cross-reactivities between the three MLS were observed in 31/322 (9.6%) of the allergological explorations.

CONCLUSION

This study highlights the possibility of cross-reactivity among and between MLSs. Dermatologists and allergologists managing patients with HSR to MLSs should be aware of a risk of cross-reactivity among the macrolides and between the different classes of MLS and to perform MLSs allergological testing before recommending an alternative antibiotic, especially in severe drug hypersensitivity from the MLS family.

Adverse drug reaction related to drug shortage: A retrospective study on the French National Pharmacovigilance Database

AIM

Drug shortages are a growing global health issue. The aim of the study was to evaluate the consequences of drug shortages on patient safety based on data recorded in the French National Pharmacovigilance Database.

METHODS

All cases involving drug shortages reported from 1985 to the end of 2019 were extracted from the database.

RESULTS

Following the selection process, 462 cases were included. The number of cases increased significantly from 2004 to 2019. Cases mainly involved drugs from the nervous system (22.1%, 95% confidence interval [CI] 17.5-27.0%), the cardiovascular system (16.4%, 95% CI 11.9-21.4%) and anti-infectives for systemic use (14.3%, 95% CI 9.7-19.2%) ATC classes. Most of the cases reported an adverse drug reaction (ADR) belonging to the SOC nervous system (21%, 95% CI 18-24%), skin and subcutaneous (14%, 95% CI 11-17%), general (13%, 95% CI 10-17%) and gastrointestinal (8%, 95% CI 5-11%) disorders. Disease worsening was observed in 15.9% of the cases, mostly related to a lack of efficacy of the replacement drug. Half of the cases were considered as serious. Evolution was favourable in 79.4% of the cases. Death and/or life-threatening situations were reported in 5.8% of the cases. Medication errors (MEs) were identified in 51 cases (11%), mostly occurring at the administration step and involving a human factor.

CONCLUSION

This study emphasizes the clinical impact of drug shortage in terms of ADRs, ME and inefficiency. These observations underline the importance of a global health policy programme to limit the occurrence of drug shortages and to reinforce the information provided to patients and health care professionals in this context to limit risk.

Renal Safety Profile of EGFR Targeted Therapies: A Study from VigiBase® the WHO Global Database of Individual Case Safety Reports

Kidney EGFR expression together with reported cases of glomerular diseases in the context of anti-EGFR drug administration raise concerns about the renal safety profile of these drugs. This issue is addressed in a case/non-case study carried out on VigiBase®, the WHO global database of individual case safety reports (ICRS). Disproportionality analysis of renal adverse effects related to the selected anti-EGFR drugs, erlotinib, gefitinib, afatinib, osimertinib, cetuximab and panitumumab, was assessed using the reporting odds ratio (ROR). Nine hundred and eighty-nine ICRSs were included. A signal of disproportionate reporting (SDR) was found for afatinib (ROR = 2.70; 95% CI [2.22-3.29]) and erlotinib (ROR = 1.73; 95% CI [1.46-2.04]) with acute kidney injury, and for afatinib (ROR = 2.41; 95% CI [1.78-3.27]), cetuximab (ROR = 1.42; 95% CI [1.14-1.78]) and erlotinib (ROR = 2.23; 95% CI [1.80-2.77]) with renal failure. The preferred term "diarrhoea" was frequently reported in the included cases. An SDR was found for erlotinib with haemolytic and uremic syndrome (ROR = 4.01; 95% CI [1.80-8.94]) and thrombotic microangiopathy (ROR = 4.94; 95% CI [2.80-8.72]). No SDR was seen for glomerular or tubule-interstitial diseases. This study showed that the anti-EGFR drug renal toxicity is mainly related to renal failure in the context of digestive toxicity.

Spontaneous Reports of Serious Adverse Drug Reactions Resulting From Drug-Drug Interactions: An Analysis From the French Pharmacovigilance Database

Few data are available on the clinical impact of drug-drug interactions (DDIs). Most of the studies are limited to the analysis of exposure to potential DDI or the targeted impact of the combination of a few drugs or therapeutic classes. The analysis of adverse drug reaction (ADR) reports could be a mean to study generally the adverse effects identified due to a DDI. Our objective was to describe the characteristics of ADRs resulting from DDIs reported to the French Pharmacovigilance system and to identify the drugs most often implicated in these ADRs. Considering all ADR reports from January 01, 2012, to December 31, 2016, we identified all cases of ADR resulting from a DDI (DDI-ADRs). We then described these in terms of patients' characteristics, ADR seriousness, drugs involved (two or more per case), and ADR type. Of the 4,027 reports relating to DDI-ADRs, 3,303 were related to serious ADRs. Patients with serious DDI-ADRs had a median age of 76 years (interquartile range: 63-84); 53% were male. Of all serious DDI-ADRs, 11% were life-threatening and 8% fatal. In 36% of cases, the DDI causing the ADR involved at least three drugs. Overall, 8,424 different drugs were mentioned in the 3,303 serious DDI-ADRs considered. Altogether, drugs from the "antithrombotic agents" subgroup were incriminated in 34% of serious DDI-ADRs. Antidepressants were the second most represented therapeutic/pharmacological subgroup (5% of serious DDI-ADRs). Among the 3,843 ADR types reported in the 3,303 serious DDI-ADRs considered, the most frequently represented were hemorrhage (40% clinical hemorrhage; 6% biological hemorrhage), renal failure (8%), pharmacokinetic alteration (5%), and cardiac arrhythmias (4%). Hemorrhagic accidents are still an important part of serious ADRs resulting from DDIs reported in France. The other clinical consequences of DDIs seem less well identified by pharmacovigilance. Moreover, more than one-third of serious DDI-ADRs involved at least three drugs.

Delayed thrombocytopenia following administration of abciximab: Pharmacovigilance survey and literature review

BACKGROUND

Abciximab (ABX) is used for acute coronary syndrome and unstable angina. Thrombocytopenia is a frequent adverse effect described as occurring in the first 24hours. The aim of this study was to evaluate, in a context of pharmacovigilance survey, the occurrence of delayed thrombocytopenia following ABX infusion in pharmacovigilance database reports and in the literature.

METHODS

Individual case safety reports (ICSRs) of delayed thrombocytopenia-between 3 and 30 days - with ABX presented as a single suspect were selected in VigiBase®, the WHO global database of ICSRs. The French cases were then extracted from the French national pharmacovigilance database. In addition, a literature review of published cases was performed using PubMed.

RESULTS

Among the 84 ICSRs selected from VigiBase®, 43 were also reported in the FPVD. Mean age was 60.1±12.3 years with a majority of male patients (77.4%). The average time to onset (TTO) was 8.9±5.2 days. Thrombocytopenia regressed in 5.1±2.7 days. Haemorrhagic complications were reported in 15% of ICSRs. In the French cases, the median nadir of platelet count was 28×10⁹/L (range 1-110) with a majority of grade 4 thrombocytopenia (39.5%). The literature review identified 42 cases and provided additional information on administered therapies, which include platelet units, corticosteroids, and IV immunoglobulins. GPIIb/IIIa-ABX complex antibodies were described in 26 published cases.

CONCLUSION

Delayed thrombocytopenia, probably due to immune reaction, is a possible life-threatening adverse effect of ABX with a mean TTO of 9 days, supporting the recommendation of a platelet count monitoring during at least two weeks. This recommendation was added to the abcximab SmPC in 2019.

Drug-induced vitiligo: a case/non-case study in Vigibase® , the WHO pharmacovigilance database

Vitiligo is a common depigmenting disorder ensuing the loss of epidermal melanocytes. It is a multifactorial disease with immunological, genetic and environmental factors including drug exposure. The purpose of the study was to investigate the drugs and therapeutic subclasses associated with vitiligo occurrence reported in VigiBase^® , the WHO pharmacovigilance database. A case/non-case study was carried out by defining cases as vitiligo reports and non-cases as all other reports. The reporting odds ratio (ROR) was calculated for the 'suspected' drugs and drug classes according to ATC level 4. During the study period, 741 cases of vitiligo were registered. Mean age was 49 ± 20 years. The disproportionality analysis showed an association between vitiligo and pembrolizumab (ROR 116.9, 95% Confidence Interval (CI) 94.8, 144.3), nivolumab (ROR 22.6, 95% CI 15.8, 32.4), ipilimumab (ROR 41.7, 95% CI 25.0, 69.7), imiquimod (ROR 152.8, 95% CI 103.0, 226.7), adalimumab (ROR 3.8, 95% CI 2.5,5.8), infliximab (ROR 2.6, 95% CI 1.65, 4.01), alemtuzumab (ROR 27.8, 95% CI 17.6, 43.9), and ustekinumab (ROR 9.3, 95% CI 5.6, 15.6). Concerning the pharmacological classes ATC level 4, a significant association was found with monoclonal antibodies, interferons, selective immunosuppressants, TNF-alpha inhibitors, interleukin inhibitors, and topical antivirals. This study confirmed the expected associations between vitiligo and immune checkpoint inhibitors and strengthened the emerging signal about the association between vitiligo and imiquimod, TNF-alpha inhibitors and interferons. New signals were shown with selective immunosuppressants including alemtuzumab and interleukin inhibitors.

Drug interactions related to self-medication: a French pharmacovigilance database study

Self-medication (SM) is a common practice perceived by patients as harmless which can, however, entail health risks. The aim of the study was to identify drug-drug interactions (DDIs) involving SM drugs leading to adverse drug reactions (ADRs) in the National French Pharmacovigilance Database. All ADR reports from 1 January 1985 to 31 July 312018, coded as 'interaction' and 'self-medication', were selected and studied. Patient characteristics, the level and type of interaction, and the therapeutic classes of the drugs were examined. Adverse drug reactions were analysed and classified according to the system organ classes of the Medical Dictionary for Regulatory Activities. One hundred and three reports totalling 158 ADRs (71% severe cases) were included; 153 DDIs (59.5% pharmacodynamic) involving 234 drugs were identified. The latter included 119 SM drugs (51% available on prescription), mainly analgaesics, anti-inflammatory drugs, dietary supplements and antibiotics. Haemostasis disorders and renal failure were the most frequently reported ADRs. The analysis of reference documents raised concerns on the lack of information provided by package leaflets. In conclusion, the present study highlights the risks of medically unapproved re-use of prescription drugs or the consumption of dietary supplements without monitoring possible interactions and ADRs. Patient awareness could be improved by more regular updates of medication package inserts.

Liquid formulation of ifosfamide increased risk of encephalopathy: A case-control study in a pediatric population

BACKGROUND

Several clusters of encephalopathy occurred after the market change from Holoxan® (ifosfamide lyophilized powder) to Ifosfamide EG® (liquid formulation) and justified a formal survey in 2015. In June 2016, the regulatory authority decided to apply a precautionary measure in reducing the shelf life of Ifosfamide EG® at 7 months. One-year study from spontaneous reports lead to suspect a potential residual risk. Due to the many limitations associated with spontaneous notifications, we performed a multicentric observational study, aiming to better explore this pharmacovigilance signal.

METHODS

We performed a case-control study in pediatric oncology Departments of 25 university hospitals between July 1st, 2016 and July 1st, 2018. All children (<18 y.o.) receiving liquid formulation or lyophilized powder formulation during the study period were included. Patients with at least one occurrence of encephalopathy were considered as cases. Logistic regression model was used to estimate the odds ratio of encephalopathy between exposure groups.

RESULTS

During the study period, 52 cases and 495 controls were included. A residual over-risk of encephalopathy was associated with ifosfamide 7-month shelf-life liquid formulation compared to lyophilized powder (adjusted OR 1.91, 95% CI: 1.03-3.53).

CONCLUSIONS

Observed difference does not seem to be related to the pathology treated, the doses used, the co-medications, a meningeal localization and/or an irradiation of the central nervous system. This study confirms data from spontaneous reports that led to the precautionary measure for the liquid formulation. Even if the risk of encephalopathy seems reduced, our study suggests the persistence of a residual risk of encephalopathy associated with liquid formulation compared to the lyophilized powder.

Ballasting by cryogenic gypsum enhances carbon export in a Phaeocystis under-ice bloom

Mineral ballasting enhances carbon export from the surface to the deep ocean; however, little is known about the role of this process in the ice-covered Arctic Ocean. Here, we propose gypsum ballasting as a new mechanism that likely facilitated enhanced vertical carbon export from an under-ice phytoplankton bloom dominated by the haptophyte Phaeocystis. In the spring 2015 abundant gypsum crystals embedded in Phaeocystis aggregates were collected throughout the water column and on the sea floor at a depth below 2 km. Model predictions supported by isotopic signatures indicate that 2.7 g m⁻² gypsum crystals were formed in sea ice at temperatures below −6.5 °C and released into the water column during sea ice melting. Our finding indicates that sea ice derived (cryogenic) gypsum is stable enough to survive export to the deep ocean and serves as an effective ballast mineral. Our findings also suggest a potentially important and previously unknown role of Phaeocystis in deep carbon export due to cryogenic gypsum ballasting. The rapidly changing Arctic sea ice regime might favour this gypsum gravity chute with potential consequences for carbon export and food partitioning between pelagic and benthic ecosystems.

Integrating ecotoxicity and chemical approaches to compare the effects of ZnO nanoparticles, ZnO bulk, and ZnCl2 on plants and microorganisms in a natural soil

This work compared the toxicity of ZnO nanoparticles (ZnO-NPs), ZnO bulk, and ZnCl2 on microbial activity (C and N transformations and dehydrogenase and phosphatase activities) and their uptake and toxic effects (emergence, root elongation, and shoot growth) on three plant species namely wheat, radish, and vetch in a natural soil at 1000 mg Zn kg(-1). Additionally, plants were also tested at 250 mg Zn kg(-1). The effects of the chemical species on Zn extractability in soil were studied by performing single and sequential extractions. ZnCl2-1000 presented the highest toxicity for both taxonomic groups. For microorganisms, ZnO-NPs demonstrated adverse effects on all measured parameters, except on N transformations. The effects of both ZnO forms were similar. For plants, ZnO-NPs affected the growth of more plant species than ZnO bulk, although the effects were small in all cases. Regarding accumulation, the total Zn amounts were higher in plants exposed to ZnO-NP than those exposed to ZnO bulk, except for vetch shoots. The soil sequential extraction revealed that the Zn concentration in the most labile forms (water soluble (WS) and exchangeable (EX)) was similar in soil treated with ZnO (NP and bulk) and lower than that of ZnCl2-treated soil, indicating the higher availability of the ionic forms. The strong correlations obtained between WS-Zn fraction and the Zn concentrations in the roots, shoots, and the effects on shoot weight show the suitability of this soil extraction method for predicting bioavailable Zn soil for the three plant species when it was added as ZnO-NPs, ZnO bulk, or ZnCl2. In this work, the hazard associated with the ZnO-NPs was similar to ZnO bulk in most cases.

Toxicity of ZnO nanoparticles, ZnO bulk, and ZnCl₂ on earthworms in a spiked natural soil and toxicological effects of leachates on aquatic organisms

The present study assessed the uptake and toxicity of ZnO nanoparticles (NPs), ZnO bulk, and ZnCl₂ salt in earthworms in spiked agricultural soils. In addition, the toxicity of aqueous extracts to Daphnia magna and Chlorella vulgaris was analyzed to determine the risk of these soils to the aquatic compartment. We then investigated the distribution of Zn in soil fractions to interpret the nature of toxicity. Neither mortality nor differences in earthworm body weight were observed compared with the control. The most sensitive end point was reproduction. ZnCl₂ was notably toxic in eliminating the production of cocoons. The effects induced by ZnO-NPs and bulk ZnO on fecundity were similar and lower than those of the salt. In contrast to ZnO bulk, ZnO-NPs adversely affected fertility. The internal concentrations of Zn in earthworms in the NP group were greater than those in the salt and bulk groups, although bioconcentration factors were consistently <1. No relationship was found between toxicity and internal Zn amounts in earthworms. The results from the sequential extraction of soil showed that ZnCl₂ displayed the highest availability compared with both ZnO. Zn distribution was consistent with the greatest toxicity showed by the salt but not with Zn body concentrations. The soil extracts from both ZnO-NPs and bulk ZnO did not show effects on aquatic organisms (Daphnia and algae) after short-term exposure. However, ZnCl₂ extracts (total and 0.45-μm filtered) were toxic to Daphnia.

Comparison of the ocean inherent optical properties obtained from measurements and inverse modeling

A model developed recently by Loisel and Stramski [Appl. Opt. 39, 3001-3011 (2000)] for estimating the spectral absorption a(lambda), scattering b(lambda), and backscattering b(b)(lambda) coefficients in the upper ocean from the irradiance reflectance just beneath the sea surface R(lambda, z = 0(-)) and the diffuse attenuation of downwelling irradiance within the surface layer ?K(d)(lambda)?(1) is compared with measurements. Field data for this comparison were collected in different areas including off-shore and near-shore waters off southern California and around Europe. The a(lambda) and b(b)(lambda) values predicted by the model in the blue-green spectral region show generally good agreement with measurements that covered a broad range of conditions from clear oligotrophic waters to turbid coastal waters affected by river discharge. The agreement is still good if the model estimates of a(lambda) and b(b)(lambda) are based on R(lambda, z = 0(-)) used as the only input to the model available from measurements [as opposed to both R(lambda, z = 0(-)) and ?K(d)(lambda)?(1) being measured]. This particular mode of operation of the model is relevant to ocean-color remote-sensing applications. In contrast to a(lambda) and b(b)(lambda) the comparison between the modeled and the measured b(lambda) shows large discrepancies. These discrepancies are most likely attributable to significant variations in the scattering phase function of suspended particulate matter, which were not included in the development of the model.

Differential expression of antenna and core genes in Prochlorococcus PCC 9511 (Oxyphotobacteria) grown under a modulated light-dark cycle

The continuous changes in incident solar light occurring during the day oblige oxyphototrophs, such as the marine prokaryote Prochlorococcus, to modulate the synthesis and degradation rates of their photosynthetic components finely. How this natural phenomenon influences the diel expression of photosynthetic genes has never been studied in this ecologically important oxyphotobacterium. Here, the high light-adapted strain Prochlorococcus sp. PCC 9511 was grown in large-volume continuous culture under a modulated 12 h-12 h light-dark cycle mimicking the conditions found in the upper layer of equatorial oceans. The pcbA gene encoding the major light-harvesting complex showed strong diel variations in transcript levels with two maxima, one before the onset of illumination and the other near the end of the photoperiod. In contrast, the mRNA level of psbA (encoding the reaction centre II subunit D1), the monocistronic transcript of psbD (encoding D2) and the dicistronic transcript of psbDC were all tightly correlated with light irradiance, with a minimum at night and a maximum at noon. The occurrence of a second peak during the dark period for the monocistronic transcript of psbC (encoding one of the PS II core Chl a antenna proteins) suggested the involvement of post-transcriptional regulation. Differential expression of the external antenna and core genes may constitute a mechanism of regulation of the antenna size to cope with the excess photon fluxes that Prochlorococcus cells experience in the upper layer of oceans around midday. The 5' ends of all transcripts were mapped, and a conserved motif, 5'-TTGATGA-3', was identified within the putative psbA and pcbA promoters.

First Detection of Faba bean necrotic yellow virus in Spain

Faba bean necrotic yellow virus (FBNYV) was not detected during 1994 to 1996 field surveys of faba beans (Vicia faba L.) in Spain (1). In 1997, however, one sample with symptoms of necrosis, collected in Baleares, was tested using ELISA (enzyme-linked immunosorbent assay) and was positive for both Tomato spotted wilt virus (TSWV) and FBNYV. FBNYV is a single-strand DNA virus that is transmitted by aphids and is the main virus disease of broad bean in North Africa and West Asia (2). During 1997 to 1999, faba bean plants with symptoms of necrosis, yellowing, small leaves, and stunting were collected from several fields in the Murcia Region (Spain) and were analyzed using ELISA. To detect FBNYV, we used monoclonal 2E9 supplied by H. J. Vetten (Institute of Plant Virology, Microbiology and Biosafety, BBA, Braunschweig, Germany). Of 700 samples analyzed, 34 were positive for FBNYV. Of the 34 positive samples, 12 tested positive, using commercial antiserum from Loewe, Inc. (Munich) for mixed infections with TSWV. FBNYV was transmitted to healthy faba bean plants by aphids (Acyrthosiphon pisum) in greenhouse experiments and was confirmed by ELISA. Preliminary epidemiological data showed a gradual increase in the number of plants infected with time in the same field. Aphid transmission of FBNYV to faba beans has established the disease in Spain and is a potential threat to other leguminous crops. This is the first report of a nanovirus in Europe. References: (1) J. Fresno et al. Plant Dis. 81:112, 1997. (2) L. Katul et al. Ann. Appl. Biol. 123:629, 1993.

[Multiple vulvar cystic and papillary fibroadenomas]

We report a new case of multiple vulvar fibroadenoma arising in a 47-year-old woman. This papillary and cystic lesion shares similarities with papilliferum hidradenoma and mammary fibroadenomas. After describing clinical and pathological characteristics, we try to detail its origin according to the literature and particularly its relationship with anogenital sweat glands and ectopic mammary glands.

PCR amplification of the gene acmA differentiates Lactococcus lactis subsp. lactis and L. lactis subsp. cremoris

The occurrence of the acmA gene, encoding the lactococcal N-acetylmuramidase in new lactococcal isolates from raw milk cheeses, has been determined. Isolates were genotypically identified to the subspecies level with a PCR technique. On the basis of PCR amplification of the acmA gene, the presence or absence of an additional amplicon of approximately 700 bp correlated with Lactococcus lactis subspecies. L. lactis subsp. lactis exhibits both the expected 1,131-bp product and the additional amplicon, whereas L. lactis subsp. cremoris exhibits a single 1,131-bp fragment.

Virus Diseases of Broad Bean in Spain

Broad bean (Vicia faba L.) plants showing symptoms suggestive of viral infection, such as stunting, leaf roll, mosaic, chlorosis, necrosis, and yellowing, were observed in the Andalucia, Baleares, Cataluna, and Murcia regions of Spain. A 4-year field survey showed the presence of five viruses: bean leaf roll luteovirus (BLRV), beet western yellows luteovirus (BWYV), bean yellow mosaic potyvirus (BYMV), tomato spotted wilt tospovirus (TSWV), and cucumber mosaic cucumovirus (CMV). Identity of viruses was first determined by enzyme-linked immunosorbent assay and confirmed by at least one other method, such as inoculation to plant hosts, electron microscopy, molecular hybridization, or immunocapture-reverse transcriptase-polymerase chain reaction. Of the 250 samples assayed, 93 were positive for BYMV, 21 for BLRV, 10 for BWYV, 30 for TSWV, and 2 for CMV. Faba bean necrotic yellow virus (a single-strand DNA virus) and broad bean mottle bromovirus, which are widely distributed in the Mediterranean basin, were not detected in the samples analyzed. BYMV was distributed in all regions, whereas TSWV was restricted only to Mediterranean areas. To our knowledge, this is the first report of viruses infecting broad bean in Spain.

[The role of ultrasound-guided puncture in the evaluation of liquid tumors of the ovary]

Twenty percent of liquid tumors of the ovary are persistent functional cysts. Laboratory tests of the cystic fluid should make it possible to distinguish between functional cysts and organic cysts. In 170 patients derived from a multicenter study and presenting with a liquid tumor of the ovary (including 9% of cancers), samples of the cystic fluid and serum were taken from the patient and the ACE, CA 125, CA 19-9 markers, estradiol and Progesterone were assayed. The results of these assays were subjected to computerized analysis and compared with the pathological findings. The assays were able to discriminate between organic cysts and functional cyst with 93% of sensitivity and 95% specificity. The insufficient reliability of this evaluation justified a second study (in progress) which is limited to the study of pure fluid tumors with thin walls, no partitions, no vegetations and measuring less than 8 cm in diameter in which the incidence of cancers is very low. This study should fine tune the initial findings and result in a sensitivity approaching 100 percent. If this hypothesis is confirmed, it should be possible to include ultrasound-guided puncture carried out under closely defined conditions in the therapeutic decision trees for liquid cysts of the ovary.

Quantification of low levels of rainbow trout immunoglobulin by enzyme immunoassay using two monoclonal antibodies

An enzyme immunoassay has been developed for quantitation of low levels of trout immunoglobulin (Ig). This assay uses two monoclonal antibodies, one as capture antibody and the other as detector, directed against two non-overlapping epitopes on the heavy chains of trout Ig. The assay shows high reproducibility and can detect 0.12 micrograms trout Ig ml-1. Coefficients of intra- and interassay variation ranged from 3.8 to 7.1% and from 7.9 to 17.4%, respectively. Analysis of 37 healthy trout showed increasing serum Ig concentration with size. The mean Ig concentration was 0.67 mg ml-1 for trout of about 20 g and 9.1 mg ml-1 for trout weighing more than 125 g.

Deliberate hypotension with nicardipine or nitroprusside during total hip arthroplasty

To induce deliberate hypotension during anesthesia, nicardipine was administered to patients undergoing total hip arthroplasty and was randomly compared with nitroprusside. Hemodynamic measurements were performed before and 10, 20, 30, and 60 min after starting to administer either nicardipine (n = 12) or nitroprusside (n = 12) (B, T1, T2, T3, and T4, respectively); at the end of drug infusion (T5); and 10, 20, and 60 min later (T6, T7, and T8, respectively). Plasma renin activity and catecholamine levels were measured at B, T1, T5, T6, and T7. In addition, plasma nicardipine concentration was measured in five patients at T1, T2, T5, T7, and T8. As with nitroprusside, nicardipine administration (1-3 micrograms.kg-1.min-1, after a titration dose of 4.7 +/- 1.5 mg) resulted in hypotension (up to -34% +/- 3%), a decrease in systemic vascular resistances (up to -49% +/- 4%), and increases in heart rate (up to +17% +/- 6%), cardiac index (up to +37% +/- 8%), plasma norepinephrine (up to +63% +/- 17%) and epinephrine (up to +232% +/- 68%) levels, and plasma renin activity (up to +336% +/- 207%). Ten and 20 minutes after discontinuation of the hypotensive drug, nicardipine led to persistent vasodilation and hypotension, which differed significantly from the hypertensive rebound observed after nitroprusside discontinuation, despite a similar increase in plasma renin activity and catecholamine levels. Our results indicate that after the infusion was terminated, the nicardipine-induced vasodilation was opposed to the vasoconstrictive effects of angiotensin II and catecholamines, thus avoiding hypertensive rebound.(ABSTRACT TRUNCATED AT 250 WORDS)

[A rare cause of postoperative acute respiratory insufficiency: diaphragmatic hernia]

A case of postoperative failure after total hip replacement is described. A gastric tube was passed and the stomach was seen to be within the right hemithorax on the chest X-ray. Aspiration of gastric gas and juice relieved the respiratory symptoms.

Serological evidence of human infection with the paramyxovirus Yucaipa in Senegal, West Africa

Sera from 353 people resident in Dakar, Senegal, West Africa, were tested for hemagglutination-inhibiting antibodies against the avian paramyxovirus Yucaipa. Antibodies were demonstrated in five sera (1.4%), providing new evidence that this virus may infect humans.

[Caudal anesthesia in infants and children]

Caudal analgesia may be used with general anaesthesia in painful surgery. Caudal anaesthesias were performed by the authors, as the single anesthetic technic for digestive or orthopedic surgery in nine children. The technic is sure, efficient and without any complications. Caudal anaesthesia seems to be interesting in the child with respiratory pathology or with morphologic facial abnormalities.