Six years of experience in laparoscopic surgery of esophageal achalasia

BACKGROUND

We show the experience of 6 years in laparoscopic surgical therapy of esophageal achalasia, performing of the Heller-Dor or Heller-Toupet operation, with particular regard to the technical aspect.

METHODS

One hundred and ten laparoscopic interventions were done between November 1995 and December 2001. We studied operative time in hiatus approach, esophagocardiomyotomy, transoperative endoscopy, and anti-reflux procedure. We also analyzed the relation between complications and clinical evolution of disease with clinical stage.

RESULTS

The mean surgical time of the intervention is 138 min, and it is significantly increased by transoperative endoscopic control; conversion to open surgery was not necessary. Clinical results are classified as excellent in 103 patients. Morbidity was 6%.

CONCLUSION

This surgical procedure is a first line in the treatment of esophageal achalasia. It is necessary to have special care in early diagnostic cases to avoid electrosurgical injury.

[Pseudomonas aeruginosa bacteremia: clinical and epidemiological patterns and treatment]

Pseudomonas aeruginosa bacteremia has the highest mortality among Gram-negative infections. We studied its clinical and epidemiological patterns in order to achieve an early and accurate diagnosis and treatment. We prospectively studied 211 cases of P. aeruginosa bacteremia admitted to our hospital from 1991 to 1998. All patients had at least one positive blood culture for P. aeruginosa and clinical symptoms of bacteremia. The prognosis of the underlying disease, past illnesses, foci location, initial clinical status, type of bacteremia, complications, and the type of antibiotic treatment were analyzed. Clinical and microbiological controls were carried out at baseline, at the end of the treatment period, and 1 month later. Of the 211 cases, 73% were men with a mean age of 56.5 years. Overall, 45.5% were hospitalized in the ICU, 28% in the surgical ward, and 26% in the medical service, with a mean length of stay of 40.4 days. As risk factors we identified a length of stay more than 14 days (76.7%), previous manipulations (87.6%), and surgery (44.5%). A total of 43.1% had had an infection in the last 6 weeks, and 46.4% were treated with antibiotics, usually broad-spectrum antibiotics without activity against P. aeruginosa. The most frequent underlying diseases were neoplasia (25.5%), postsurgical cardiopathy (24.1%), nephrosis (22.7%), chronic obstructive pulmonary disease (17.5%) and diabetes (13.2%). The most frequent foci were pulmonary (29.3%), urinary (21.8%), and undetermined (38.3%). The mortality rate was 27.9% and was considered related to P. aeruginosa bacteremia in 76.2% of the cases. The antibiotic treatment was considered adequate in 89% of the cases. It was concluded that knowledge of the clinical and epidemiological factors of patients with P. aeruginosa bacteremia may help to optimize its management and to reduce its morbidity and mortality.

Correlation between the activity of different fluoroquinolones and the presence of mechanisms of quinolone resistance in epidemiologically related and unrelated strains of methicillin-susceptible and -resistant Staphylococcus aureus

OBJECTIVE

To study the activity of five different fluoroquinolones against 22 epidemiologically related and unrelated strains of Staphylococcus aureus (13 methicillin-resistant (MRSA) strains and nine methicillin-susceptible (MSSA) strains) in which the mechanisms of quinolone resistance are also investigated.

METHODS

The MICs of the different fluoroquinolones were determined by the microdilution method, in the presence and absence of reserpine. The quinolone resistance-determining regions of the gyrA, gyrB, grlA and grlB genes were amplified and sequenced to establish the presence of mutations. The molecular epidemiology of the 22 strains was performed by low-frequency restriction analysis of chromosomal DNA with SmaI.

RESULTS

MSSA strains showed lower homology than MRSA strains, in which only two clones were seen. Trovafloxacin showed the best activity against these clinical isolates of S. aureus, since strains carrying one amino acid change in both GyrA and GrlA subunits remained susceptible to this antimicrobial agent. Furthermore, trovafloxacin did not seem to be a substrate for NorA.

CONCLUSION

Trovafloxacin was the most active quinolone tested against S. aureus strains, followed by levofloxacin and sparfloxacin, whereas ciprofloxacin and norfloxacin were the least active quinolones, in both the presence and absence of reserpine. Epidemiologically related S. aureus strains presented different mechanisms of quinolone resistance, suggesting a divergent evolution of the same clone. Finally, 16 S. aureus strains with a ciprofloxacin plus reserpine MIC > or = 1 mg/L already showed a mutation in the grlA gene. This MIC may be useful as a marker of mutation in this gene, contraindicating the use of this quinolone, since a second mutation may develop during treatment.

[Hypertonic saline 7.5% in the treatment of severe hypochloremic metabolic alkalosis]

A 63 year-old man with a history of anal carcinoma treated by surgery, chemotherapy and radiotherapy was admitted to our hospital two years later with small bowel obstruction requiring emergency surgery. Fifteen days later, he had to be operated on once again. During the procedure, severe metabolic alkalosis developed: pH 7.58, CO3H- 47.7 mmol/L and a base excess of 24.3 mmol/L. The patient had the following preoperative risk factors for hypochloremic metabolic alkalosis: low levels of Cl and K, prolonged aspiration of gastric contents, low plasma volume and parenteral nutrition. Metabolic alkalosis was managed with 250 mL of 7.5% hypertonic saline, 40 mEq of KCl, readjustment of the ventilatory pattern, perfusion of lactated Ringer's solution instead of 0.9% saline and administration of omeprazole. Response to treatment was good as elevated values fell to acceptable levels within two hours. Metabolic alkalosis is a common acid-base balance disorder which arises for a variety of reasons and which has significant anesthetic implications. Hypertonic saline may be useful for treating severe, acute hypochloremic metabolic alkalosis.

Are quinolone-resistant uropathogenic Escherichia coli less virulent?

The prevalence of hemolysin, type 1 fimbriae, P fimbriae, cytotoxic necrotizing factor-1 (CNF-1), aerobactin, and autotransporter toxin (sat) was analyzed by polymerase chain reaction and phenotypic assays of 42 epidemiologically unrelated Escherichia coli strains causing acute pyelonephritis in women (21 nalidixic acid-susceptible and 21 nalidixic acid-resistant strains) and 58 E. coli strains causing cystitis in women (29 nalidixic acid-susceptible and 29 nalidixic acid-resistant strains). Hemolysin and CNF-1 were less prevalent (P<.05) in nalidixic acid-resistant than in nalidixic acid-susceptible E. coli strains from patients with either pyelonephritis (14.3% vs. 52.4%) or cystitis (0% vs. 31.0%). Among E. coli strains causing cystitis, type 1 fimbriae expression was less prevalent (P<.05) in the nalidixic acid-resistant group (55.2%) than in the nalidixic acid-susceptible group (86.2%). None of the nalidixic acid-resistant and 20.7% of the nalidixic acid-susceptible strains causing cystitis showed the proteolytic toxin Sat (P<.05). These results suggest that resistance to quinolones may be associated with a decrease in the presence or the expression of some virulence factors in uropathogenic E. coli.

Structure-based QSAR study on differential inhibition of human prostaglandin endoperoxide H synthase-2 (COX-2) by nonsteroidal anti-inflammatory drugs

The prostaglandin-endoperoxide H synthase-1 (PGHS- 1) and prostaglandin-endoperoxide H synthase-2 (PGHS-2) are the targets of nonsteroidal anti-inflammatory drugs (NSAIDs). It appears that the high degree of selectivity for inhibition of PGHS-2 shown by certain compounds is the result of two mechanisms (time-dependent, time-independent inhibition), by which they interact with each isoform. Molecular models of the complexes formed by indomethacin, sulindac, fenamates, 2-phenylpropionic acids and selective cyclooxygenase-2 (COX-2) inhibitors with the cyclooxygenase active site of human PGHS-2 have been built, paying particular attention to water molecules that participate in the hydrogen-bonding network at the polar active site entrance. The stability of the complexes has been assessed by molecular dynamics simulations and interaction energy decomposition analysis, and their biological significance has been discussed in light of available X-ray crystallographic and kinetic results. The selective PGHS-2 inhibitors exploit the extra space of a side-pocket in the active site of PGHS-2 that is not found in PGHS-1. The results suggest that active site hydration together with residues Tyr355, Glu524, Arg120 and Arg513 are crucial to understand the time-dependent inhibition mechanism. A marked relationship between the isoform selectivity and tightly interactions with residues into the side pocket bordered by Val523 is also found.

Unusual malignant tumours in patients with HIV infection

The clinical charts of 2560 HIV-infected patients seen in our Unit between 01/89 and 08/01 were reviewed. All patients with a neoplasm were analysed to study the prevalence of tumours other than Kaposi's sarcoma (KS), non-Hodgkin's lymphoma (NHL) or cancer of the cervix. There were 43 unusual malignant tumours: 13 lung cancers, six leukaemias, six skin cancers, two carcinomas of the conjunctiva, two cancers of the penis, three of the anus, three of the larynx, one sarcoma of the ureter, one gastric carcinoid, one non-differentiated thyroid carcinoma, one non-differentiated prostate carcinoma, one cancer of the tongue, one cancer of the bladder, one adenocarcinoma of the rectum and one multiple IgM myeloma. Thirteen (43.3%) of the patients died, 10 (76.9%) from causes related to the tumour itself. These results suggest that HIV-infected patients have a higher prevalence of some neoplasms than the general population.

A major Archean, gold- and crust-forming event in the Kaapvaal craton, South Africa

The 2.89- to 2.76-gigayear-old conglomerates of the Central Rand Group of South Africa host an immense concentration of gold. The gold and rounded pyrites from the conglomerates yield a rhenium-osmium isochron age of 3.03 +/- 0.02 gigayears and an initial 187Os/188Os ratio of 0.1079 +/- 0.0001. This age is older than that of the conglomerates. Thus, the gold is detrital and was not deposited by later hydrothermal fluids. This Middle Archean gold mineralization event corresponds to a period of rapid crustal growth in which much of the Kaapvaal craton was formed and is evidence for a significant noble metal flux from the mantle.

[Invasive pneumococcal disease in children in the region of Murcia (Spain)]

OBJECTIVE

Because of the availability of a conjugate pneumococcal vaccine, the incidence and characteristics of invasive pneumococcal disease in children in the region of Murcia should be determined. This would provide information that could be useful for properly establishing the indications for vaccination.

METHODS

A retrospective search was conducted for cases of invasive Streptococcus pneumoniae in children aged less 15 years old treated in hospitals in Murcia from 1991-2000. The data sources were the databases of the microbiology services, the Minimum Data Set, the Pediatric Admissions Register and the EDO Register.

RESULTS

The incidence rate for the period 1996-2000 was 18.25 per 105 children per year for children aged under 1 year in the case of invasive disease (10.6 for meningitis), 13.6 for those under 2 years for invasive disease (6 for meningitis), 8.9 for those under 5 years (1.35 for meningitis) and 3.7 for those under 15 years (1.3 for meningitis). Twenty-eight percent of the patients presented risk factors. Complications occurred in 35.2% and sequelae occurred in 5%. The mortality rate was 11.8%. The prevalent serogroups were 19, 6, 18, 5, 14 and 23.

CONCLUSIONS

The high percentage of patients with risk factors for invasive pneumococcal disease suggests the need to implement vaccination programs aimed at risk groups. Although the incidence of invasive pneumococcal disease in the region of Murcia differs from that in other areas, the incidence of meningitis is similar to that reported by other studies. Because of the severity of the disease, cost-effectiveness studies to evaluate the possible incorporation of the vaccine in the vaccination calendar are justified.

[Functional insulin therapy: patient education and algorithms]

Functional insulin therapy is a teaching approach of intensified insulin therapy. Its aim is to transfer to the patient the decisional process and the management of its insulin treatment, this according to the various acts of everyday life, and particularly meals. The principles of functional insulin therapy, the pedagogic approach, the benefits observed in type 1 diabetic patients (better diabetes control, and particularly decrease in the number of severe hypoglycaemic events) are briefly described - Nevertheless, to apply this functional insulin therapy in practice, requires a specific teaching program preferably ambulatory in real everyday life conditions, and carried out by a staff highly qualified in diabetology.

Activities of six different quinolones against clinical respiratory isolates of Streptococcus pneumoniae with reduced susceptibility to ciprofloxacin in Spain

Six quinolones were tested on 817 consecutive pneumococcal isolates for which ciprofloxacin MICs were high (> or =2 microg/ml); the isolates had been collected during two recent Spanish surveillance studies. For strains for which the ciprofloxacin MIC was >or =4 microg/ml, the MICs at which 90% of the isolates tested against gemifloxacin, moxifloxacin, gatifloxacin, sparfloxacin, levofloxacin, and ofloxacin were inhibited were 0.25, 1, 1, 1, 4 and 16 microg/ml, respectively, and the corresponding prevalences of resistance were 0, 1, 4.5, 9.5, 8.4 and 23%. The proportion of isolates for which the ciprofloxacin MIC is high has increased over time.

Monitoring volatile compounds during dry-cured ham ripening by solid-phase microextraction coupled to a new direct-extraction device

Key flavour volatile compounds were monitored during ripening of dry-cured ham by solid-phase microextraction (SPME) coupled to a new direct-extraction device (DED). DED allows the insertion of the SPME fibre into the core of solid materials with no damage to the fibre. This enables extraction of volatiles from solid foodstuffs while avoiding sample handling. Major groups of volatile compounds extracted with SPME-DED agreed with available scientific literature about dry-cured ham volatiles. Moreover, volatile compounds previously highlighted as quality markers in dry-cured ham, such as 3-methylbutanal or hexanal, were satisfactorily extracted using SPME-DED. Changes in the profile of volatile compounds throughout the processing followed a typical pattern of volatile compounds formation. Therefore, SPME-DED appears as a new and promising method for monitoring ripening of dry-cured hams with no depreciation of the product, which might substitute traditional subjective methods currently used in the ham processing industry. However, the use of the internal standard method is not possible with this technique. Therefore, results using SPME-DED only point out a trend in the volatile profile. Further attempts relating data obtained using SPME-DED in dry-cured hams with sensory and chemical data from the same samples would be necessary for optimising this method as a quality control method in dry-cured ham industries.

Effect of pre-incubation storage conditions on hatchability, chick weight at hatch and hatching time in broiler breeders

1. Eggs were stored for two different times at varying temperatures. The effects on hatchability, chick weight at hatch and hatching time were examined in two broiler breeder lines from 33 to 58 weeks of age. 2. Short storage (1 to 3 d). Storage at 20 degrees C compared with 16.5 degrees C reduced hatchability of all eggs set. No effect was observed on hatchability of fertile eggs, hatching time or chick weight. 3. Long storage (9 to 11 d). Storage at 16.5 degrees C compared with 10 degrees C decreased both hatchability of fertile eggs and chick weight at hatch. Incidence of early embryonic death increased and incubation time decreased at 16.5 degrees C compared with 10 degrees C. 4. Chicks from morning eggs were heavier than those from afternoon eggs irrespective of storage conditions. 5. Hatchability (all eggs set and fertile eggs) and chick weight varied with hen age irrespective of storage conditions. During long storage, hatching time varied with hen age independently of breeder line, storage temperature or egg laying time. 6. Hatchability (all eggs set and fertile eggs) was higher in line A than in line B. Line B eggs hatched later and produced heavier chicks than line A eggs irrespective of storage time.

Gene therapy of hepatocellular carcinoma

The extraordinary versatility of gene therapy opens new possibilities for the treatment of incurable diseases, including hepatocellular carcinoma. Gene therapy strategies against tumors include prodrug activation therapy by the transfer of suicide genes, immunogene therapy, tumoral cell phenotype correction by the inhibition of oncogenes or the transfer of tumor suppressor genes, antiangiogenesis and transfer of oncolytic viruses. The experience accumulated during the last decade of clinical gene therapy indicates that genes can be expressed inside the tumor tissue, but the overall results of the studies conducted so far are still disappointing, mainly due to the poor performance of the currently available gene therapy vectors. This review covers the general aspects of gene therapy vectors, preclinical data available in animal models of hepatocellular carcinoma, and finally a brief summary of the gene therapy clinical trials aimed at the treatment of liver cancer.

Off-flavour release from packaging materials and its prevention: a foods company's approach

Off-flavours in packed food are causes for consumer complaints. Often, they are related to packaging materials. For food companies, this represents not only costs related to production, but also a possible loss of brand confidence and market share. The origin of packaging-related off-odours are many sided. Odours derive from the degradation of base packaging materials and their converting processes, including printing, coating and lamination as well as the interaction between food and packaging. Many substances and groups of substances have been identified so far. In spite of the fact that the quality of packaging materials is clearly defined in the specifications (e.g. limit for residual solvents, standardized odour and taste transfer tests), off-flavour cases still do occur. This paper sets out ways of avoiding such problems, even in factories and laboratories which are not so well equipped. Prevention at Nestlé is based on several pillars. For a number of years, a sensory panel at the central laboratory has been specialized in and trained on packaging off-favours. The panel can describe and identify odours and their origin. To confirm the results by instrumental analysis, various extraction and separation techniques are available, including distillation/extraction techniques and direct thermal desorption followed by gas chromatography coupled with mass spectroscopy and an olfactory sniffing port. However, this knowledge must also be present in the operational plants where the problem usually originates. To manage this knowledge transfer, two tools were introduced to build up sensory panels that can evaluate packaging material. First, an aroma library kit was developed that contained odours that are often involved in off-odour cases. For each odour, a typical descriptor and the chemical composition are given. Beside that, information is added about the occurrence. Second, a glossary, which contains descriptors for packaging-related off-odours, was published. This small booklet helps to unify the odour descriptions, especially thanks to its translation into three important languages. This paper describes the tools mentioned above, as well as examples and limitations for their application.