An IgG antibody response to the antigen 85 complex is associated with good outcome in Mexican Totonaca Indians with pulmonary tuberculosis.

SETTING: It is generally accepted that antibodies do not protect against Mycobacterium tuberculosis infection, as this role relies upon T-cell reactivity. Hence, most studies on antimycobacterial antibodies have been aimed at developing serologic tests, and few explore their role in disease pathogenesis. OBJECTIVE: To determine the IgG antimycobacterial antibody response of 55 Mexican Totonaca Indians with pulmonary tuberculosis and its correlation with some features of the disease. DESIGN: Study of the profile of antigen recognition by immunoblot and ELISA with isolated antigen 85 complex (Ag85) and whole culture filtrate proteins. Correlation of immunoblot and ELISA results with BCG vaccination, tuberculin reactivity, extent of the disease, clinical setting, and response to treatment. RESULTS: On immunoblot, band reactivity was very poor and the most frequently recognized antigen was the 30-32 kDa, antigen 85 complex (45.8% of serum samples). ELISA with this antigen showed a sensitivity of 72% and a specificity of 100%. Positive antibody titers to Ag85 were observed in 79.4% of patients with non-cavitary tuberculosis (P = 0.012) and in 95.8% of patients who were cured with anti-tuberculosis chemotherapy (P = 0.0001). By contrast, an antibody response to whole culture filtrate antigens had no correlation with the presence of cavitations or with prognosis. CONCLUSIONS: Our data show that an antibody response to Ag85, aside from having great potential to develop a serologic test for tuberculosis, was associated with a positive outcome in a cohort of tuberculous Mexican Indians.

Step-down management of gastroesophageal reflux disease.

BACKGROUND & AIMS: As the economic burden of gastroesophageal reflux disease (GERD) is largely weighted to maintenance as opposed to initial therapy, switching from more potent to less expensive medication once symptoms are alleviated (step-down therapy) may prove to be most cost-effective. This study aimed to prospectively evaluate the feasibility of step-down therapy in a cohort of patients with symptoms of uncomplicated GERD. METHODS: Patients whose GERD symptoms were alleviated by proton pump inhibitors (PPIs) were recruited from outpatient general medicine clinics. After baseline demographic and quality of life information were obtained, PPIs were withdrawn from subjects in a stepwise fashion. Primary outcome was recurrence of symptoms during follow-up that required reinstitution of PPIs. Secondary outcomes included changes in quality of life and overall cost of management. Predictors of nonresponse to step-down were assessed. RESULTS: Seventy-one of 73 enrolled subjects completed the study. Forty-one of 71 (58%) were asymptomatic off PPI therapy after 1 year of follow-up. Twenty-four of 71 (34%) required histamine 2-receptor antagonists, 5/71 (7%) prokinetic agents, 1/71 (1%) both, and 11/71 (15%) remained asymptomatic without medication. Quality of life did not significantly change, whereas management costs decreased by 37%. Multivariable analysis revealed younger age and a dominant symptom of heartburn to predict PPI requirement. CONCLUSIONS: Step-down therapy is successful in the majority of patients and can decrease costs without adversely affecting quality of life.

Developmental instability and working memory ability in children: a magnetic resonance spectroscopy investigation.

This study of children (ages 7 through 12) wishes to determine (a) whether variation in frontal lobe brain chemistry, determined from proton magnetic resonance spectroscopy (1H-MRS), is related to performance on a working memory task in children, and (b) whether developmental instability (DI; the imprecise expression of the genetic plan for development due to several known genetic and environmental effects) underlies phenotypic variation in brain chemistry. 1H-MRS assessed neurometabolites in a right frontal white matter voxel. The Visual Two-Back test assessed working memory. A composite measure of DI was created from measures of minor physical anomalies, fluctuating asymmetry of body characteristics, and fluctuating asymmetry of dermatoglyphic features. Greater DI strongly predicted lower concentrations of creatine-phosphocreatine (Cre) and choline-containing compounds, whereas Cre and N-acetyl-aspartate positively correlated with working memory skills. Working memory skills thus seem related to frontal lobe energy metabolism, which in turn is related to DI.

A review of hemolytic uremic syndrome in patients treated with gemcitabine therapy.

BACKGROUND: Hemolytic uremic syndrome (HUS) is a rare condition that occasionally is reported in cancer patients. Recently it has been observed that gemcitabine rarely may be associated with this condition. METHODS: The manufacturer's safety database and literature were reviewed for any report regarding gemcitabine associated with renal and hematologic abnormalities. Descriptive analysis was used to examine each case for an association between gemcitabine therapy and HUS and to identify its incidence and risk factors. RESULTS: Through December 31, 1997, 12 cases were identified that fit either the clinical (uremia, microangiopathic hemolytic anemia, and thrombocytopenia) or pathologic (renal biopsy) criteria for HUS. There were 7 males (58%) and 5 females (42%) with a median age of 55.5 years (range, 37-73 years). The median duration of gemcitabine therapy was 5.8 months (range, 3.8-13.1 months). Six patients died, five improved, and one patient's outcome was unknown. Among the six deaths, three patients died of cancer progression, one patient died of an unrelated myocardial infarction, and two patients died of HUS or HUS-related complications. For the five patients who improved, treatment was comprised of dialysis, plasmapheresis, splenectomy, or a combination. Attempts to correlate patient demographics, primary malignancy, and cumulative gemcitabine dose failed to identify consistent risk factors in predisposing patients to HUS. Confounding factors were common, including mitomycin-C and/or 5-fluorouracil exposure, advanced stage tumors, or preexisting renal dysfunction. CONCLUSIONS: Based on a patient exposure of 78,800, a crude overall incidence rate of 0.015% (range, 0.008-0.078%) was determined, showing that HUS associated with gemcitabine treatment appears to be rare. Nonetheless, as with other cancer treatments, clinicians should weigh the appropriate risk/benefit ratio in using gemcitabine to treat their patients.

[Pleurodesis with the patient's own blood: the initial results in 14 cases]. / Pleurodesis con sangre del propio paciente: resultados iniciales en 14 casos.

Fourteen adults with spontaneous pneumothorax (SP), 9 of whom had primary SP (PSP) and 5 of whom had secondary forms (SSP), were given intrapleural infusions of self-donated blood for pleurodesis. Instillations of 50 ml were given to all except 1, who required a total volume of 120 ml. The procedure was performed in each patient's bed in all cases. With apical chest tube placement in most cases and the lung expanded, the outer tip of the tube was elevated and the patient's own blood was taken from a superficial forearm vein and instilled. Them, with the tube occluded, the patient's were rotated un bed for a period of 2 hours to distribute the blood evenly throughout the pleural cavity. Tolerance was excellent, with no pain reported by any patient. The only noteworthy complication was 1 case of infectious pleural effusion of unknown etiology which was treated by evacuation and antibiotics. In 13 (92%) patients closure of the fistula was achieved, in under 12 h in 7 (53%), in under 24 h in 3 (23%), in under 48 h in 2 (15%), and in under 72 h in the remaining 2 (15%). In 4 (28.5%) there was recurrence (2 SSP and 2 PSP patients). Over a 10 to 32 month follow-up period (mean 16 months), 10 (71.4%) patients experienced no recurrences or complications. These results allow us to speculate that blood instilled in the pleural cavity may act in 2 ways: in the short term as a blood patch that adheres to and closes the fistula in the visceral pleura, and over the longer term by creating pleural symphysis by adhesions and fibrous tissue. Our limited experience indicates that pleurodesis with self-donated blood is an easy-to-perform, painless, convenient, rapid and inexpensive procedure that is moderately effective in the short and medium term. Its main drawbacks are the lack of consensus on certain technical considerations, such as the optimum amount of blood to be instilled, the number of instillations to perform and, if multiple instillations are carried out, what the interval between them should be. Further study is needed to confirm or discount our results and to determine the place this technique may have in the clinical management of pneumothorax.

[Morbidity-mortality due to exchange transfusion in a general hospital. A prospective study]. / Morbimortalidad por exanguinotransfusión en un hospital general. Estudio prospectivo.

In this prospective study, the complications and mortality appeared in 50 exchange transfusions (ET) were analyzed. The ET were performed in 84% of the cases through a catheter in the umbilical vessels, 22 through both vessels, 10 by vein and 10 by umbilical artery; in the rest of cases by central vein. We found complications in 33% of the cases. Cardiac arrhythmia (23 cases) was the most frequent complication; also metabolic complications in 20 cases, septic complications in 10 cases (8 cases of omphalitis and 4 of sepsis were included), 8 cases of necrotizing enterocolitis and 3 of bleeding were found. Some of the newborns has 2 or more complications at the same time. The total lethality rate was 4% which occurred in 2 preterm infants with critical state. Our finding suggest that morbidity due to ET is highest than previously reports and maybe the mortality is due to the critical state of patients more than the ET.

[Multisystemic impact in the full-term newborn with perinatal asphyxia]. / Repercusión multisistémica en el recién nacido a término con asfixia perinatal.

We studied 30 full-term newborn infants, admitted to the newborn intensive care unit of "Manuel Gea González" General Hospital between January 1, 1989 and December 31, 1990. All infants had 5-minute Apgar score of 5 or less. The disturbances related to: brain, heart, liver, bowel, coagulation system, calcium and glucose homeostasis were investigate in all cases. Of the 30 infants, 29 (97%) had developed 1 to 7 abnormalities in the systems studied. Most of them had from 2 to 5 abnormalities (77%). The commonest disturbance was brain involvement in 22 cases (73%); metabolic and coagulation changes had also been observed, while heart disturbances were less common. There was no significant difference between the intensity and number of systemic abnormalities observed in these infants and the alterations seen during pregnancy, labor, delivery, administration of anesthesia and Apgar score. These observations suggest a striking relationship between asphyxia in the newborn infant and the development of systemic disturbances.

[Principal problems limiting community participation in water supply and sanitation projects]. / Principales problemas que limitan la participación comunitaria en los proyectos de abastecimiento de agua y saneamiento.

For community participation to be active and sustained, effective communication is needed between the institutions charged with promoting these activities and the population that is to benefit from the programs in view, particularly economically deprived and rural populations. In this document the author considers the obstacles he observed in Guatemala to the promotion of water supply and sanitation systems, and suggests measures for surmounting them. He also proposes a series of general strategies for making the community an active participant in these activities.

Principales problemas que limitan la participacion comunitaria en los proyectos de abastecimiento de agua y saneamiento. / Main problems restricting community participation in the water supply and sanitation projects

Para conseguir que la participacion de la comunidad sea activa y sostenida,es preciso que se produzca una comunicacion efectiva entre las instituciones encargadas de la promocion de estas actividades y la propria poblacion que se va a beneficiar de los programas de que se trate, en especial la marginada y la que vive en el area rural. En este documento el autor examina los obstaculos que ha observado en su experiencia en Guatemala en relacion con la promocion de sistemas de abastecimiento de agua y saneamiento y sugiere las medidas que se pueden tomar para superar las dificultades. Asimismo, propone una serie de estrategias generales que pueden adoptarse para lograr una activa participacion de la comunidad en estas actividades

[Early liver damage caused by alcohol]. / Lesiones hepáticas tempranas por alcohol.

Liver biopsy was taken from 20 patients with chronic and acute alcoholism. The patients had been hospitalized for diverse reasons, had no clinical manifestations of alcoholic hepatitis nor cirrhosis, but did have abnormal liver function tests. The most common abnormal test results were low serum albumin, polyclonal gamma-globulin elevation, and S G O T and Alk P rise. In all patients one or more types of hepatic lesiones were found: steatosis (15), polynuclear and mononuclear infiltrates (15), and portal (7), interstitial (13), or centriobular (8) fibrosis. Two patients had cirrhosis. None had hepatic cell necrosis. These findings justify a motivated search for liver damage in patients with alcoholism who have slight alterations in liver function tests, even in the absence of clinical manifestations of liver disease.

[Uremia and hypothyroidism. Report of a case]. / Uremia en hipotiroidismo. Informe de un caso.

It was diagnosed hypothyroidism in a 53-year-old man with chronic renal failure, with blood urea of 306 mg/dl and serum creatinine of 14.9 mg/dl. At three months of triiodothyronine therapy, the patient became asymptomatic and blood urea and serum creatinine diminished to 49 and 1.1 mg/dl respectively. The possible mechanisms responsible of that reversible uremia of such unusual amount in this hypothyroid patient are discussed.