Long-term follow-up of a randomized prospective trial comparing a standard 81 mg dose of intravesical bacille Calmette-Guérin with a reduced dose of 27 mg in superficial bladder cancer.

OBJECTIVES: To determine the efficacy of a three-fold reduced dose (RD, 27 mg) of intravesical bacille Calmette-Guérin (BCG) against the standard dose (81 mg) in patients with superficial bladder cancer, assessing recurrence, progression and differences in toxicity. PATIENTS AND METHODS: Five hundred patients with superficial bladder cancer (Ta, T1, Tis) were enrolled and randomly assigned to be treated after transurethral resection of all visible lesions with intravesical BCG Connaught strain (weekly x six and thereafter fortnightly x six) either with the standard or RD instillation. RESULTS: All but one of the 500 patients were evaluable for efficacy and toxicity (252 in the standard arm and 247 in the RD arm). The median follow-up was 69 months (maximum 104); 71 (28%) patients in the standard arm and 76 (31%) in the RD arm developed recurrences; the median time to recurrence has not yet been attained, but at 5 years the mean (sd) percentage of recurrence-free patients was 70.5 (3.12) and 70.4 (3.1) for the standard and RD arms, respectively. In patients presenting with multifocal tumours, the standard dose was more effective against recurrences than the RD (P=0.0151). In those with G3 and high-risk tumours overall, the superiority of the standard dose was marginal (P=0.060 and P=0.082). Twenty-nine (11.5%) tumours in the standard arm and 33 (13.3%) in the RD arm progressed to invasive disease; the median time to progression has not yet been attained, but the percentage of progression-free patients at 5 years was 88.8 (2.23) and 86.9 (2.31) for the standard and RD arms, respectively. The standard dose was more effective than the RD against progression only in patients with multifocal disease (P=0.048). Twelve (4.8%) cystectomies were performed in the standard and 15 (6.1%) in the RD arm. Currently, 106 (21.2%) patients have died, but only 38 (7.6%) from bladder cancer, i.e. 20 (7.9%) in the standard and 18 (7.5%) in RD arm. Overall the disease-specific death rate was lower for those patients who completed the scheduled treatment. The cause-specific survival at 5 years did not differ between the arms (P=0.76) but there was a trend toward better cause-specific survival for patients with multifocal tumours in the standard arm. Toxicity differed between the arms, significantly more patients having no toxicity in the RD arm, and fewer having delayed instillations or withdrawing. However, severe systemic toxicity occurred even in patients treated with the RD, in a similar proportion to those receiving the standard dose. CONCLUSION: Overall, the RD gave similar results for recurrence and progression but with significantly less toxicity. However, patients with multifocal tumours fared better with the standard dose and there was a trend towards better recurrence rates in patients with high-risk tumours. We recommend continuing to use the standard dose for high-risk tumours, while we consider the reduced dose safe and effective for intermediate-risk lesions and for maintenance schedules.

[Course of serologic positivity to Chagas disease in a rural community in Brazil]. / Evolução da positividade sorológica para a doença de Chagas numa comunidade rural brasileira.

In order to assess the evolution of seropositivity for Chagas' disease in the rural community of Cássia dos Coqueiros, in São Paulo state, we compared two cross-sectional studies performed at that site in 1971-1972 and in 1989-1991. In the first survey the complement fixation test was used to determine seropositivity for the disease. In this study, the total prevalence of Chagas' disease was found to be 16.6%, with values ranging from 2.9 to 61.9% (in the 10-19 and 50-59 year age groups, respectively). In the 1989-1991 study, in which indirect immunofluorescence was used, the total prevalence dropped to 10.1%, with a minimum of 0.4% (in the 10-19 year age group) and a maximum of 44.8% (in persons over 60 years of age). Among subjects born in Cássia dos Coqueiros, the 1989-1991 study showed seropositivity after age 38, with only one exception (a 24-year-old man). The drop in the seropositivity index for Chagas' disease in Cásia dos Coqueiros during the period under study can be partially attributed to socioeconomic factors, such as improved living conditions and the progressive abandonment of rural areas. Thus, our results point to the spraying of households with residual insecticides, which began in 1950, as the pivotal factor in the fight against triatomine bugs and in disease control. These results suggest that transmission may have been interrupted as early as the latter part of 1954 and later consolidated as a result of improved socioeconomic conditions and the elimination of Triatoma infestans from the study area.

[Treatment of systemic arterial hypertension with urapidil. Study in mild and moderate hypertension with ambulatory monitoring of arterial pressure]. / Tratamento da hipertensão arterial sistêmica com urapidil. Estudo na hipertensão leve e moderada com monitorização ambulatorial da pressão arterial.

PURPOSE: To study the efficacy and tolerability of urapidil in patients with mild and moderate arterial hypertension, including ambulatory blood pressure monitoring (ABPM). METHODS: Twenty patients, either sex, 40 to 75 years old, with diastolic blood pressure (DBP) between 90 to 115mmHg were studied. The DBP was the follow-up criterion measured by conventional esphygmomanometer. The 24 hours ambulatory monitoring of BP was made to observe its variation. After wash-out of 15 days, urapidil was administered starting with 60 mg/day, during two weeks, followed by 120mg/day and 180mg/day if necessary, to achieve th protocol baseline of 90mmHg or less of DBP. It followed 8 weeks treatment. Laboratory tests, EKG, monitoring of BP and clinical evaluation was made at pre and post treatment period, with clinical examinations every two weeks. RESULTS: In 15 (75%) patients the BP was controlled according to the protocol criteria (p < 0.001). The control of BP was not achieved in 3 (15%) and 2 (10%) patients were withdrawn because of intolerable drug side effects. The most frequent side effects were nausea, dizziness and indisposition, but 60% of the patients did not present any one. The duration of side effects was not longer than to 30 days, except in one patient. There were no changes in laboratory results after the treatment period. The 24 hours ABPM showed an improvement in the pattern of hypertension, maintaining the BP circadian rhythm. CONCLUSION: Urapidil demonstrated to be effective and safe in the treatment of patients with mild and moderate arterial hypertension, showing good control of BP levels, without changing the laboratory parameters.

Uso de anastomose mecanica com grampeador EEA nas varizes sangrantes do esofago. / The use of mechanical anastomosis with EEA stapler in esophageal bleeding varices

O uso da anastomose mecanica com grampeador EEA nas varizes sangrantes do esofago associada a esplenectomia, desvascularizacao esofagogastrica, vagotomia troncular e piloroplastia e apresentado como mais uma alternativa para os pacientes com hipertensao portal sangrado macicamente. O metodo foi usado em 6 pacientes com 2 obitos no pos-operatorio, nao havendo em nenhum dos casos ressangramento

Investigación interamericana de mortalidad en la niñez: peso al nacer en la región de Ribeirao Preto, Sao Paulo / Inter-American investigation of mortality in childhood: birthweight in the region of Ribeirao Preto, Sao Paulo

La información sobre el peso al nacer reviste gran importancia para los estudios de las causas de mortalidad en la niñez. El registro cuidadoso de este dato permite conocer, ante todo, la frecuencia con que ocurre el bajo peso al nacer, que constituye un factor importante en los grupos de mayor mortalidad, especialmente en el primer mes de vida. Sirve asimismo de base para las investigaciones que intentan aclarar las causas asociadas al bajo peso al nacer. El propósito de este artículo es demostrar el valor de esta clase de datos para la recopilación del conjunto de información básica sobre salud (AU)