Aspirin-like defect in platelet secretion on a patient undergoing cardiac valve and coronary graft surgery. Perioperative management

We show the case of an adult male with a previous diagnosis of an 'aspirin-like' defect in platelet secretion responses scheduled for cardiac valve surgery. Perioperative management and bleeding prevention were made following experts' recommendations.     

A study of a rural telemedicine system in the Amazon region of Peru

Voice and data communication facilities (email via VHF radio) were installed in 39 previously isolated health facilities in the province of Alto Amazonas in Peru. A baseline study was carried out in January 2001 and a follow-up evaluation in May 2002, after nine months of operation. We measured the reliability of the technology and the effect the system had on staff access to medical training and information. We also measured the indirect effects on the general population of access to better health-care. The experimental data were collected from 35 of the 39 sites in face-to-face questionnaire interviews. Before installation of the system, the mean consultation rate was 3 per month per facility (95% CI 1.5 to 4.5). At the end of the study, the mean consultation rate was 23 per month per facility (95% CI 14.7 to 31.5). There were 205 emergency transfers from the 39 health facilities. The system was employed in all these cases to alert the referral centre. The mean time required for evacuation was reduced from 8.6 h to 5.2 h. Health-care personnel reported that in 58 of the emergency cases (28%) the use of the system saved the life of the patient. The study shows that the use of communication technologies appropriate to local needs solves many problems in rural primary care, and that voice and email communication via VHF radio are feasible and useful for rural telemedicine.     

Response of ApoA-IV in pigs to long-term increased dietary oil intake and to the degree of unsaturation of the fatty acids

ApoA-IV is a protein constituent of HDL particles; the gene coding for it is a member of the ApoA-I-ApoC-III-ApoA-IV cluster. To investigate the effects of the quantity and the degree of saturation of dietary lipid on the long-term response of this Apo, and on the hypothetical coordinated regulation of the cluster in vivo, pigs were fed isoenergetic, cholesterol-free, low-lipid or lipid-enriched diets (containing either extra olive oil (rich in MUFA) or sunflower oil (rich in n-6 PUFA)) for 42 d. In animals fed on the control diet, ApoA-IV was mainly associated with plasma lipoproteins. An increase in plasma ApoA-IV concentration, mainly in the lipoprotein-free fraction, was induced by the lipid-enriched diets, independent of the degree of saturation of the fatty acids involved. The latter diets also led to increases in hepatic ApoA-I, ApoA-IV and ApoC-III mRNA levels, more so with the sunflower oil-rich diet. The present results show that porcine plasma ApoA-IV levels and their association with lipoproteins are very sensitive to increases in dietary lipids, independent of the degree of fatty acid saturation. Furthermore, hepatic expression of RNA appears to be coordinated along with that of the other members of the gene cluster.     

Recurrent hepatitis C genotype 1b following liver transplantation: treatment with combination interferon-ribavirin therapy

BACKGROUND: Recurrent hepatitis C is very common leading to graft cirrhosis in a significant proportion of patients. Preliminary reports of combination therapy with interferon-ribavirin have been promising but generally applied to selected patients with chronic mild disease. Little is known, however, about the efficacy and risk of adverse effects when it is used in general clinical practice. AIMS: To analyse the efficacy (biochemical, virological and histological response) and tolerance of combination therapy in patients with recurrent hepatitis C genotype 1b. METHODS: Twenty-four patients (mean age 54 years; range 37-67 years; 75% male) with recurrent hepatitis C virus (histology at baseline: acute hepatitis (n = 3); chronic hepatitis (n = 21) with F3 or 4 in 77%) were treated with 12 months interferon (1.5-3 MU thrice weekly) + ribavirin (600-1200 mg daily) followed by 6 months ribavirin (58%), at a median of 427 days (56-2812) after transplantation. RESULTS: Seven patients (29%) discontinued therapy due to side effects, mainly anaemia, at a median of 3 months since initiation. Dose modifications were required in 88% of those completing the whole course of therapy. Overall, the sustained virological and biochemical response was 12.5%. This rate was slightly higher (18%) if only the 17 patients who finished the whole course of therapy were analysed. Histological improvement was achieved in 31.5% of treated patients. CONCLUSIONS: Combination therapy has a very limited efficacy in the liver transplant setting, although some benefit may be achieved, even in those with advanced graft fibrosis. Tolerance, however, remains a matter of concern.     

Melanoma metastasis is associated with enhanced expression of the syntenin gene

Primary cutaneous melanomas and melanoma metastases were examined for differential gene expression using subtractive suppression hybridization in a search for any genes associated with metastasis. Generating a subtracted library of candidate genes up-regulated in melanoma metastases, this library contained 8 different cDNAs, among them a cDNA fragment of the syntenin gene which was overexpressed in further independent melanoma resection specimens on cDNA Southern blots when compared to acquired melanocytic nevi from which melanomas are known to arise. Upon immunohistochemistry, the syntenin protein expression was detected in the cytoplasm of primary cutaneous melanomas and melanoma metastases. Melanoma metastases exhibited higher proportions of tumour cells positive for syntenin immunostaining in comparison to acquired melanocytic nevi or non-metastasizing primary melanomas which was statistically significant. In addition to melanoma, gastric cancer tissues exhibited a higher syntenin mRNA expression on a matched tumour/normal cDNA array than their normal counterparts which was statistically significant. Altogether, we here first describe the detection of the syntenin protein in resection specimens of melanocytic lesions. We conclude that melanoma metastasis is associated with increased expression of the syntenin gene which may participate in signal transduction and cell adhesion via the multifunctional protein-binding properties of its tandem PDZ domains.     

High risk Ewing's sarcomas. Effectiveness and toxicity of a regimen designed for children and used in adults

Introduction

Ewing's sarcoma is a highly malignant small round-cell tumor arising primarily from bone. Adults with this neoplasm have a poorer survival than that of children. The Spanish Society of Paediatric Oncology (SEOP) recommends that high-risk patients be treated with a combination of 5 different drugs (EVAIA schedule). The objective of this study is to evaluate response, overall survival, dose intensity and toxicity of the SSOP protocol in adult patients with high-risk Ewing's sarcoma.

Material and methods

Between 1997 and 2001, 16 adults with a histological diagnosis of high-risk Ewing's sarcoma were treated according to SEOP recommendations. Median age was 23 years (range: 15–42). Enneking staging system indicated 7 patients (44%) were II-B and 9 patients (56%) at stage III.

Results

The responses were: 12 complete responses (75%), 1 partial response (6%), 2 patients with stable disease and 1 disease progression. At the time of the present analysis, 6 patients (38%) were alive and free of disease, 1 (6%) was alive with disease and 9 patients had died (8 of them due to disease progression and 1 secondary to a second line chemotherapy administered after EVAIA). Median survival was 21 months (range: 9–67) and median time to progression was 14 months (range: 6–23).

Conclusions

EVAIA protocol is an aggressive regimen in which the most frequent toxicity is granulocytopenia and anaemia. In our experience no deaths were due to this protocol. The use of EVAIA in first-line therapy achieved 81% response rate with a high rate of long-term survival in this patient population with poor prognosis.     

Multiple coronary embolisms in a woman with risk factors for thromboembolic disease

We report the case of a 33-years-old woman, smoker and taking oral contraceptives, who presented to the emergency room with an anterior ST-elevation myocardial infarction. Thrombolytic treatment was initiated and a few minutes after, chest pain returned and an inferior ST-segment-elevation infarction was diagnosed at that moment. Catheterization revealed multiple embolic occlusion of coronary branches. We discuss tests performed and pathophysiology of myocardial infarction in this patient.