Perioperative Myocardial Injury After Noncardiac Surgery: Incidence, Mortality, and Characterization

BACKGROUND

Perioperative myocardial injury (PMI) seems to be a contributor to mortality after noncardiac surgery. Because the vast majority of PMIs are asymptomatic, PMI usually is missed in the absence of systematic screening.

METHODS

We performed a prospective diagnostic study enrolling consecutive patients undergoing noncardiac surgery who had a planned postoperative stay of ≥24 hours and were considered at increased cardiovascular risk. All patients received a systematic screening using serial measurements of high-sensitivity cardiac troponin T in clinical routine. PMI was defined as an absolute high-sensitivity cardiac troponin T increase of ≥14 ng/L from preoperative to postoperative measurements. Furthermore, mortality was compared among patients with PMI not fulfilling additional criteria (ischemic symptoms, new ECG changes, or imaging evidence of loss of viable myocardium) required for the diagnosis of spontaneous acute myocardial infarction versus those that did.

RESULTS

From 2014 to 2015 we included 2018 consecutive patients undergoing 2546 surgeries. Patients had a median age of 74 years and 42% were women. PMI occurred after 397 of 2546 surgeries (16%; 95% confidence interval, 14%-17%) and was accompanied by typical chest pain in 24 of 397 patients (6%) and any ischemic symptoms in 72 of 397 (18%). Crude 30-day mortality was 8.9% (95% confidence interval [CI], 5.7-12.0) in patients with PMI versus 1.5% (95% CI, 0.9-2.0) in patients without PMI (P<0.001). Multivariable regression analysis showed an adjusted hazard ratio of 2.7 (95% CI, 1.5-4.8) for 30-day mortality. The difference was retained at 1 year with mortality rates of 22.5% (95% CI, 17.6-27.4) versus 9.3% (95% CI, 7.9-10.7). Thirty-day mortality was comparable among patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction (280/397, 71%) versus those with at least 1 additional criterion (10.4%; 95% CI, 6.7-15.7, versus 8.7%; 95% CI, 4.2-16.7; P=0.684).

CONCLUSIONS

PMI is a common complication after noncardiac surgery and, despite early detection during routine clinical screening, is associated with substantial short- and long-term mortality. Mortality seems comparable in patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction versus those patients who do.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02573532.

Fluorescence/luminescence-based markers for the assessment of Schistosoma mansoni schistosomula drug assays

Background

Schistosomiasis is responsible for a tremendous public health burden, yet only a single drug, praziquantel, is available. New antischistosomal treatments should therefore be developed. The accuracy, speed and objectivity of in vitro drug screening depend on the assay read-out. Microscopy is still the current gold standard and is in need of updating to an automated format. The aim of the present study was to investigate a panel of fluorescence/luminescence dyes for their applicability as viability markers in drug sensitivity assays for Schistosoma mansoni schistosomula.

Methods

A search for available viability and cytotoxicity marker assays and dyes was carried out and a short-list of the most interesting candidates was created. The selected kits and dyes were tested on S. mansoni Newly Transformed Schistosomula (NTS), first to assess whether they correlate with parasite viability, with comparatively low background noise, and to optimise assay conditions. Markers fulfilling these criteria were then tested in a dose–response drug assay using standard and experimental drugs and those for which an IC₅₀ value could be accurately and reproducibly calculated were also tested on a subset of a compound library to determine their hit-identification accuracy.

Results

Of the 11 markers selected for testing, resazurin, Vybrant® and CellTiter-Glo® correlated best with NTS viability, produced signals ≥ 3-fold stronger than background noise and revealed a significant signal-to-NTS concentration relationship. Of these, CellTiter-Glo® could be used to accurately determine IC₅₀ values for antischistosomals. Use of CellTiter-Glo® in a compound subset screen identified 100 % of hits that were identified using standard microscopic evaluation.

Conclusion

This study presents a comprehensive overview of the utility of colorimetric markers in drug screening. Our study demonstrates that it is difficult to develop a simple, cheap “just add” colorimetric marker-based drug assay for the larval stage of S. mansoni. CellTiter-Glo® can likely be used for endpoint go/no go screens and potentially for drug dose–response studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s13071-015-1233-3) contains supplementary material, which is available to authorized users.

A novel isothermal microcalorimetry tool to assess drug effects on Ancylostoma ceylanicum and Necator americanus

Soil-transmitted helminths, which affect the poorest communities, worldwide cause a range of symptoms and morbidity, yet few treatment options are available and drug resistance is a concern. To improve and accelerate anthelminthic drug discovery, novel drug screening tools such as isothermal microcalorimetry (IMC) have been tested with great potential. In this study, we used a novel microcalorimeter, the calScreener™, to study the viability on the hookworms Necator americanus and Ancylostoma ceylanicum as well as the whipworm Trichuris muris. Significant heat flow signals could be obtained with already one adult worm per channel for all three species. High-amplitude oscillations were observed for the hookworms; however, adult T. muris showed a twofold heat flow decrease during the first 24 h. Antinematodal effects of ivermectin and levamisole at 1, 10, and 100 μg/ml were evaluated on adult N. americanus and A. ceylanicum. Levamisole-treated hookworms showed a decline in heat flow and oscillation amplitude in a dose-response manner. Heat flow for ivermectin-treated hookworms increased proportionally with increased concentrations of ivermectin, though the wavelet analysis showed an opposite trend as observed by flatter wavelets. In conclusion, the calScreener™ is an excellent tool to study drug effects on intestinal hookworms at the adult worm stage as it offers a lower detection limit than other IMC devices and the possibility to monitor worm viability online.

A multicentric study regarding the use of hormone therapy during female mid-age (REDLINC VI)

BACKGROUND

Menopausal hormone therapy (HT) has shown benefits for women; however, associated drawbacks (i.e. risks, costs, fears) have currently determined its low use.

OBJECTIVE

To determine the prevalence of current HT use among mid-aged women and describe the characteristics of those who have never used, have abandoned or are currently using HT. In addition, reasons for not using HT were analyzed.

METHOD

This was a cross-sectional study that analyzed a total of 6731 otherwise healthy women (45-59 years old) of 15 cities in 11 Latin American countries. Participants were requested to fill out the Menopause Rating Scale (MRS) and a questionnaire containing sociodemographic data and items regarding the menopause and HT use.

RESULTS

The prevalence of current HT use was 12.5%. Oral HT (43.7%) was the most frequently used type of HT, followed by transdermal types (17.7%). The main factors related to the current use of HT included: positive perceptions regarding HT (odds ratio (OR) 11.53, 95% confidence interval (CI) 9.41-14.13), being postmenopausal (OR 3.47, 95% CI 2.75-4.36) and having a better socioeconomic level. A total of 48.8% of surveyed women had used HT in the past, but abandoned it due to symptom improvement or being unconcerned; fear of cancer or any other secondary effects were also reported but in less than 10%. Among women who had never used HT, 28% reported the lack of medical prescription as the main reason, followed by the absence of symptoms (27.8%). Among those reporting lack of prescription as the main reason for not using HT, 30.6% currently had severe menopausal symptoms (total MRS score > 16); 19.5% of women were using alternative 'natural' therapies, with 35.1% of them displaying severe menopausal symptoms as compared to a 22.5% observed among current HT users.

CONCLUSION

The use of HT has not regained the rates observed a decade ago. Positive perceptions regarding HT were related to a higher use. Lack of medical prescription was the main reason for not using HT among non-users, many of whom were currently displaying severe menopausal symptoms.

[Optimization of processing and storage of clinical samples to be used for the molecular diagnosis of pertussis]

Pertussis or whooping cough is an acute, highly contagious respiratory infection, which is particularly severe in infants under one year old. In classic disease, clinical diagnosis may present no difficulties. In other cases, it requires laboratory confirmation. Generally used methods are: culture, serology and PCR. For the latter, the sample of choice is a nasopharyngeal aspirate, and the simplest method for processing these samples uses proteinase K. Although results are generally satisfactory, difficulties often arise regarding the mucosal nature of the specimens. Moreover, uncertainties exist regarding the optimal conditions for sample storage. This study evaluated various technologies for processing and storing samples. Results enabled us to select a method for optimizing sample processing, with performance comparable to commercial methods and far lower costs. The experiments designed to assess the conservation of samples enabled us to obtain valuable information to guide the referral of samples from patient care centres to laboratories where such samples are processed by molecular methods.

Comparison of laboratory colonies and field populations of Tamarixia radiata, an ectoparasitoid of the Asian citrus psyllid, using internal transcribed spacer and cytochrome oxidase subunit I DNA sequences

The genetic diversity of Tamarixia radiata Waterston (Hymenoptera: Eulophidae) laboratory colonies derived from collections in China, northern Vietnam, Pakistan, and a mixed colony from Taiwan and southern Vietnam was evaluated using the internal transcribed spacer (ITS) region 1, ITS-2, and the 5' end of the cytochrome oxidase subunit I gene. The strains share the same ITS sequence, consistent with the morphological hypothesis that the collections represent a single species. The COI marker was variable and could distinguish the northern Vietnam and Pakistan colonies from each other and from the other colonies. Comparison of COI sequences from field-collected populations of Puerto Rico, Guadeloupe, and Texas indicates that Florida is not a likely source of the introduction into Puerto Rico but is a likely source of the introduction into Texas.

An updatable holographic three-dimensional display

Holographic three-dimensional (3D) displays provide realistic images without the need for special eyewear, making them valuable tools for applications that require situational awareness, such as medical, industrial and military imaging. Currently commercially available holographic 3D displays use photopolymers that lack image-updating capability, resulting in restricted use and high cost. Photorefractive polymers are dynamic holographic recording materials that allow updating of images and have a wide range of applications, including optical correlation, imaging through scattering media and optical communication. To be suitable for 3D displays, photorefractive polymers need to have nearly 100% diffraction efficiency, fast writing time, hours of image persistence, rapid erasure, and large area-a combination of properties that has not been shown before. Here, we report an updatable holographic 3D display based on photorefractive polymers with such properties, capable of recording and displaying new images every few minutes. This is the largest photorefractive 3D display to date (4 x 4 inches in size); it can be recorded within a few minutes, viewed for several hours without the need for refreshing, and can be completely erased and updated with new images when desired.

Heart sound cancellation based on multiscale products and linear prediction

This paper presents a novel method for Heart Sound (HS) cancellation from Lung Sound (LS) records. The method uses the multiscale product of the wavelet coefficients of the original signal to detect HS segments. Once the HS segments are identified, the method removes them from the wavelet coefficients at every level and estimate the created gaps by either an autoregressive or moving average model. It is shown that if the segment to be predicted is stationary, a final record with no audible artifacts such as clicks can be reconstructed using this approach. The results were promising for HS removal from LS without hampering the main components of the LS. The results were confirmed both qualitatively by listening to the reconstructed signal and quantitatively by spectral analysis.

Immunophenotypic diversity and prognosis of adult T-cell leukemia/lymphoma

17565

Background: Adult T-cell leukaemia/lymphoma (ATLL) is an aggressive disease associated with human T-cell lymphotropic virus type-I (HTLV-I) with heterogeneous clinical presentation and outcomes, described in Southern Japan, Europe, Caribbean and previously on Pacific coast of South America including Peru (EHA 2001, abst. 304). Shimoyama’s ATLL classification (BHJ 1991:79), includes four types: acute, lymphomatous, chronic and smouldering; recently a new clinical cutaneous type had been described (BJD 2005:152). Methods: We described our experienced previously (ASH 2005, abst. 4797). Herein we analyzed immunophenotypically our ATLL patient population by flow cytometry looking for aberrant phenotypes and their correlation with overall survival. The statistical method was descriptive and survival was calculated using the Kaplan-Meier method. Results: From July 1997 to March 2005 our registry had 69 cases, 37 had flow pre-treatment: acute type (n = 31) and lymphomatous (n = 6). Over our 37 flow done we were able to analysis only 33. The incidence of the typical (CD4+/CD8-) phenotype, the double-negative (CD4-/CD8-), the double-positive (CD4+/CD8+), and the CD8 positive (CD4-/CD8+) phenotypes was 58%, 12%, 15%, and 12% respectively. The median overall survival (OS) for the 33 patients was 4.1 months (range: 0.5–46.1). The patients with typical phenotypes had a median OS of 4.1 months better than the patients with the double-negative phenotype whom median OS was 2.0 (range: 1.5–9.7) but not significant. Median OS in the double positive and the CD4-/CD8+ phenotype population were 15.2 and 4.8 months respectively with no significance Conclusions: ATLL has a diversity of immunophenotype, our data suggest that there is not any correlation with survival, major accrual will gave us a final conclusion.

No significant financial relationships to disclose.

Focal Nodular Hyperplasia (FNH): A Potential Cause of False-Positive Positron Emission Tomography

Positron emission tomography (PET) using F-18 fluorodeoxyglucose (FDG) has been proven to be a useful tool in the differential diagnosis of liver tumors. Focal nodular hyperplasia (FNH) is an uncommon benign liver lesion, which can be difficult to differentiate from other benign and malignant liver pathologies. FDG PET imaging usually shows uptake similar or even decreased compared to that of the normal liver. We describe a hypermetabolic FNH lesion in a patient with a history of breast cancer. Computed tomography scan, ultrasonography (US), and magnetic resonance imaging were negative. The lesion was resected, and histologic findings were consistent with FNH.

[Bone scintigraphy and somatostatin receptor scintigraphy in pediatric patients with bone involvement in Langerhans cell histiocytosis]

Langerhans cell histiocytosis (LCH) is a granulomatous disease which can involve multiples sites of the body. Diagnostic imaging is of utmost importance in the management of these patients. Up to now radiographic skeletal survey and bone scintigraphy (BS) have been used to assess bone involvement (both with low specificity). Magnetic resonance imaging (MRI) and CT have been used to assess visceral involvement but with the limitation that they cannot give information about the functional status. Recently somatostatin receptor scintigraphy (SSRS) has been proposed to detect active lesions and to monitor response to treatment. The aim of this study is to assess bone and somatostatin receptor scintigraphy in the detection of bone involvement in LCH in children. Twenty scintigraphies (12 SSRS and 8 BS) were performed in seven patients (3 girls and 4 boys) aged at diagnosis: 18 month-12 years (mean age 6 years). The findings obtained in the scintigraphies were compared with clinical evolution and other imaging techniques. Bone scintigraphy detected all the LCH bone lesions, and discovered one unknown lesion. SSRS scintigraphy visualised the active lesions in 3 patients (clinical and other imaging techniques were also positive). SSRS was negative in one patient classified as disease free and another in clinical remission. SSRS detected 2 new unknown bone lesions, but could not detect LCH bone lesions confirmed in other imaging techniques in 2 patients. Somatostatin receptor and Bone scintigraphy can be used to detect active LCH bone lesions in children and can help to monitor response to treatment. Further studies with more patients are needed to confirm the diagnostic usefulness of these techniques.

Hodgkin's disease. Prognostic value of Gallium-67 scintigraphy

AIM

The aim of this study is to assess the clinical impact of gallium-67 scintigraphy, before and after treatment, in patients with Hodgkin's disease, and to compare the overall survival between the patients whose gallium studies after treatment were negative and those whose studies remained positive.

METHODS

We have studied 75 patients (40 women, 35 men) with Hodgkin's disease. All the patients underwent (67)Ga scintigraphy at the moment of the diagnosis (basal study) and in the case that basal study was positive (abnormal hyper-uptake focus) we performed follow-up studies after the treatment. We have calculated the overall survival among patients whose studies after treatment were negative (1(st) group) and those whose studies remained positive (2(nd) group) and between patients whose studies were negative at diagnosis (3(rd) group).

RESULTS

Gallium scintigraphy was positive at diagnosis in 47 patients (62.6%). In 39 of them we were able to perform the follow-up study after treatment. The follow-up study was negative in 31 patients while in 8 patients the gallium scintigraphy remained positive. The overall survival was significantly higher (p<0.001) in the 1(st) group compared with the 2(nd) group. The overall survival was higher in the 1(st) group compared with the 3(rd) but statistic significance level was not reached.

CONCLUSION

Our data suggest that: 1) in Hodgkin's disease (67)Ga scintigraphy is useful to establish the diagnosis of complete remission; 2) if the gallium scan remains positive after treatment, the prognosis of patients is worse than the prognosis of patients with a negative scan.

Relation between cigarette smoking and celiac disease: evidence from a case-control study

OBJECTIVES

It has been suggested that environmental factors other than gliadin might play a role in pathogenesis of celiac disease. Cigarette smoking was reported to exert a protective effect against the development of symptomatic celiac disease; however, this relationship was not confirmed. The aim of this study was to determine the effect of cigarette smoking on celiac disease.

METHODS

A cohort of 87 consecutive celiac disease patients attending the clinic of Malabsorption and 174 age- and sex-matched individuals diagnosed with functional GI disorder were included in the study. Clinical information was obtained both at the time of diagnosis and at follow-up by reviewing the clinical history. Smoking information was obtained through an in-person interview using a questionnaire.

RESULTS

Although 33% of controls were current smokers at the time of the study, only 16% of celiac patients were smokers at diagnosis (odds ratio, 0.39; 95% confidence interval 0.19-0.79; p < 0.006). The proportion of nonsmokers among patients (84%) was significantly greater than that among controls (67%; odds ratio, 2.54; 95% confidence interval 1.27-5.16; p < 0.007). Current smoker patients had a lower baseline BMI (p < 0.05) and body weight (p < 0.05) compared to former smokers. Compared with nonsmokers, control individuals who were active smokers at entry in the study were younger (p < 0.02) and had lower body weight (p < 0.03) and BMI (p < 0.03). Interestingly, positive lineal correlation was observed between age at diagnosis and daily cigarette consumption (r = 0.72; p < 0.004) in active smokers. We did not detect any relationship either between causes for cessation of smoking and clinical symptoms or between differences in the proportions of smoking habits when patients were stratified according to their clinical status at diagnosis (symptomatic vs subclinical/asymptomatic cases).

CONCLUSIONS

This study provides evidence that, compared with control subjects, a significantly lower proportion of patients with celiac disease were current smokers at the time of diagnosis, and that cigarette smoking delayed diagnosis of celiac disease. Our study suggests that the nutritional compromise of patients with celiac disease who smoked resulted from the summation of the effect of celiac disease per se and that produced by the smoking habit. Further studies are necessary to identify whether the relationship between smoking and celiac disease is causal or incidental.

Left ventricular diastolic dysfunction secondary to hyperglycemia in patients with type II diabetes

Diabetes mellitus type II, a cause of preclinical left ventricular dysfunction that can progress to cardiac insufficiency ventricular dysfunction in diabetic patients, is attributed to systemic arterial hypertension, or ischemic cardiopathy. Diastolic ventricular dysfunction takes place during the course of diabetes mellitus. The purpose of the present article is to report on the influence of hyperglycemia on the left ventricular diastolic dysfunction independently of dyslipidemia, obesity, and systemic arterial hypertension, usually present in diabetic patients. Left ventricular diastolic function was studied by Doppler echocardiography in asymptomatic type II diabetic patients without ischemic or valvular cardiopathies, cardiomegaly, or systemic arterial hypertension. Two groups of patients were integrated: patients with and without left ventricular diastolic dysfunction, i.e., groups A and B, respectively. Glycemia, cholesterol, triglycerides, and body mass index (BMI) were determined in each subject. Bivariate statistical tests (Student t, chi-square, or Mann-Whitney U tests) were applied to study the influence of the previously mentioned variables on the ventricular diastolic function. To evaluate the influence of hyperglycemia on ventricular diastolic function separately from dyslipidemia, systemic arterial hypertension, and the influence of obesity, logistic regression, and multivariate statistical analysis were applied. Independently of dyslipidemia and obesity, a relationship was found between hyperglycemia and diastolic dysfunction of the left ventricle in patients belonging to group A (p <0.05, odds ratio [OR] 12.1). No statistical significance was found between glycemia and the diastolic function of the left ventricle in group B patients. Even in type II diabetic patients without cardiopathy, uncontrolled hyperglycemia provokes diastolic left ventricular dysfunction.

Tissue transglutaminase antibodies in celiac disease: assessment of a commercial kit

OBJECTIVE

Tissue transglutaminase was identified as the autoantigen eliciting endomysial antibody. A homemade enzyme-linked immunosorbent assay (ELISA)-based test was recently developed to determine quantitative titers of IgA antitissue transglutaminase antibody. Our objective in this study was to assess the suitability of a newly developed commercial kit for quantitative determination of antibody in patients with untreated celiac disease.

MATERIALS

We tested serum samples from 79 untreated celiac patients, 42 healthy blood donors, and 18 patients with nonceliac intestinal disorders evaluated in two different centers. Samples were tested for antitissue transglutaminase, and antiendomysial and antigliadin antibodies in the center where diagnosis was performed. To assess interlaboratory variability of methods, 24 samples randomly selected were blindly tested in both centers. Antitissue transglutaminase antibodies were determined using a commercial kit (INOVA Diagnostics, Inc., San Diego, CA).

RESULTS

Untreated celiac patients had significantly higher titers of antitissue transglutaminase than healthy and disease controls (p < 0.00001). According to the cut-off provided by the manufacturers (20 AU/mL), overall sensitivity was 92% (85% for one center and 100% for the other) and specificity was 98% (100% and 95%, respectively). Antiendomysial antibody was 86% sensitive and 100% specific. Discordance between antitissue transglutaminase and antiendomysial antibodies was detected in 13% of patients. Although two antitissue transglutaminase-negative cases had a positive antiendomysial antibody, the inverse situation was found in eight cases. A blind determination of antitissue transglutaminase on the same samples evidenced a good agreement (kappa statistic: 0.66) between both centers when assessment was qualitative (based on the decision of positive or negative). Although correlation of titers for both determinations was highly significant (r: 0.902, p < 0.00001), a very wide interlaboratory variability (median: 50%) was detected when absolute values were considered.

CONCLUSIONS

The quantitative determination of antitissue transglutaminase using a commercial kit was highly sensitive and specific for detection of celiac disease. We observed an incomplete overlapping with antiendomysial antibody. The very high variability of values between laboratories still remains to be solved so as to propose the commercial ELISA assay for the screening of celiac disease.

Upper limb ischemia induced by chronic licorice ingestion

A young woman had an acute embolic episode that affected her right upper limb. An axillo-brachial thromboembolectomy was performed after which distal pulses were recovered. The patient had a long lasting history, longer than ten years, of continuous licorice ingestion. Blood samples showed severe hypokalemia that caused EKG changes. Transesophageal echocardiogram discovered mild mitral valve prolapse. The combination of surgery and potassium supplements was successful in treating this rare and potentially life-threatening disease.

Maternal urine beta-core hCG fragment level and small for gestational age neonates

OBJECTIVE

To determine whether second-trimester urine beta-core fragments of hCG predict small for gestational age (SGA) neonates.

METHODS

Spot urine beta-core levels were measured in 733 nonhypertensive women with singleton pregnancies who presented for amniocentesis and had karyotypically normal fetuses. The beta-core level was standardized to urine creatinine and expressed as multiples of the median. The area under a receiver operating characteristics curve was used to determine the screening efficiency of the urine analyte for prediction of small for gestational age (SGA) births. In a subgroup of cases, serum markers (alpha-fetoprotein [AFP], hCG, and unconjugated estriol) were compared using stepwise regression analysis to urine beta-core fragment for SGA prediction.

RESULTS

There were 23 (3.0%) SGA neonates. The mean +/- standard deviation (SD) gestation at urine collection was 16.4 +/- 1.3 weeks and collection to delivery interval was 23.0 +/- 2.2 weeks. Mean beta-core (+/- SD) fragment levels were significantly higher in those who later had SGA infants compared with appropriately grown infants (2982.8 ng/mg creatinine versus 1447.4 ng/mg creatinine, P <.001). Stepwise logistic regression found that urine beta-core fragment and serum AFP were the only significant predictors of SGA, with statistically significant chi(2) values (P <.001 and P =.038, respectively). The urine analyte was significantly superior. Second-trimester urine beta-core fragment had a 78.3% sensitivity and 70% specificity for SGA prediction. Exclusion of preeclamptic cases resulted in a sensitivity of 84.2% and a specificity of 71.2%.

CONCLUSION

Second-trimester elevated maternal urine beta-core fragment of hCG predicted SGA infants, and was superior to other serum analytes in that prediction.

Sesterterpenoid from Gentianella alborosea

The structure of a new type of sesterterpenoid, designated as alborosin, isolated from Gentianella alborosea, has been deduced from a spectroscopic investigation.

Risk of fractures in celiac disease patients: a cross-sectional, case-control study

OBJECTIVES

Although osteopenia and osteoporosis are well-recognized complications of celiac disease, no controlled studies have been done to assess the prevalence of fractures in a large cohort of patients. The objectives of this study were to determine the prevalence of bone fractures and vertebral deformities in celiacs and to analyze the relationship between fractures and clinical data of patients.

METHODS

We studied 165 patients with a well-established diagnosis of celiac disease. A similar number of age- and gender-matched control subjects with functional GI disorders were evaluated. The design of the study was cross-sectional, with a retrospective historical review through a personal interview of all subjects. All patients underwent bone mineral density measurement by dual-energy, x-ray absorptiometry and spinal x-ray. Vertebral deformities were determined by visual inspection of spinal x-rays and by morphometric analysis.

RESULTS

Among celiacs, 41 patients (25%) referred have had from one to five fractures in the peripheral skeleton. On the contrary, only 14 (8%) control subjects experienced fractures. This difference was highly significant (odds ratio, 3.5; 95% confidence interval [CI], 1.8-7.2; p<0.0001). Although inspection of spinal x-rays showed evidence of vertebral deformities in the lumbar spine in only two patients, a more detailed examination of lateral x-rays using morphometric criteria detected lumbar spine vertebral deformities in nine (five also had fractures in the peripheral skeleton) and in four controls (odds ratio, 2.8; 95% CI, 0.7-11.5; p = NS). Eighty percent of fractures were detected before the diagnosis of celiac disease or in patients who were noncompliant with the gluten-free diet; only 7% of patients experienced fractures after starting treatment. Regression analysis adjusted for multiple comparisons showed that patients with fractures were diagnosed with celiac disease later (p<0.06) and remained undiagnosed for more prolonged periods (p<0.05). There was a trend, which did not reach statistical significance, for a lower bone mineral density in the lumbar spine and total skeleton among patients with fractures.

CONCLUSIONS

This study has demonstrated that patients with celiac disease had a high prevalence of bone fractures in the peripheral skeleton. Most of these events occurred before diagnosis or while patients were noncompliant with gluten-containing diet. Our results suggest that early diagnosis and effective treatment of celiac disease were the most relevant measures to protect patients from the risk of fractures.

[Quality assurance and teamwork in social medicine expert assessment exemplified by the expert assessment aid "corrective breast surgery" of the North Rhine Health Insurance Medical Service]

To standardise sociomedical expertising procedures in surgery of the breast a project team of medical advisors of the Medical Advisory and Expertising Service North Rhine worked out a manual. A form was created for sociomedical pre-advice occasions. Detail parameters for examination (time needed and advisor selection) were fixed in consent. Checklists were worked out, which may be admitted to quality assurance procedures. The manual "Medical opinion for surgery of the breast" has been implemented and is applied in the Medical Advisory and Expertising Service North Rhine since January 1999. In the sense of teamwork participation those who were involved as team-workers became participants in decision-making. The manual "Medical opinion for surgery of the breast" may be seen as an example of quality assurance and participation in socio-medical opinion procedures. The influence of this manual on the formal quality of medical opinion will be checked.

Nuchal thickness, urine beta-core fragment level, and maternal age for down syndrome screening

OBJECTIVE

Our purpose was to report the midtrimester Down syndrome screening efficiency of a 2-analyte algorithm, urine beta-core fragment (a metabolite of human chorionic gonadotropin) and nuchal thickness, along with maternal age in a high-risk population undergoing genetic amniocentesis.

METHOD

Nuchal thickness, humerus length, and maternal urine beta-core fragment levels were measured prospectively before genetic amniocentesis in 1360 singleton pregnancies, 21 (1.5%) of which had fetal Down syndrome. All analyte levels were expressed as multiples of the normal medians based on biparietal diameter. Backward-stepwise logistic regression was used to determine whether the markers were significant independent predictors of fetal Down syndrome. Matrix analysis was used to calculate an adjusted Down syndrome likelihood ratio for each patient based on the significant screening markers. Multiplication by age-related midtrimester risk gave the adjusted Down syndrome risk. The sensitivity and false-positive rates at different Down syndrome screening thresholds were used to generate a receiver-operator characteristics curve. The area under the curve was used to assess the value of this screening test.

RESULTS

On the basis of logistic regression, beta-core fragment level (P 1/60 the sensitivity and false-positive rate for Down syndrome were 85.7% and 4.9%, respectively, when beta-core fragment level, nuchal thickness, and maternal age were used. Correspondence screening values at a risk threshold > 1/150 were 95.2% and 10.8%, respectively. The area under the receiver-operator characteristics curve was 0.9357 (SE = 0. 0137), indicating that the algorithm is excellent for Down syndrome screening.

CONCLUSION

In this study, a combination algorithm consisting of nuchal thickness, urine beta-core fragment level, and maternal age had a high screening efficiency for Down syndrome. This algorithm should be investigated as a new option for women at high risk of having a fetus with Down syndrome.

Pharmacokinetics of deflazacort in renal transplanted and hemodialyzed children

Deflazacort (DFZ) pharmacokinetics was evaluated in fifteen pediatric patients on chronic hemodialysis or after renal transplantation, and in three normal children. After overnight fasting, oral DFZ 0.26+/-0.01 mg/kg (mean +/- SEM) was given. Serial blood samples were collected for 360 min and analyzed by HPLC for 21-hydroxy-DFZ (21-HO-DFZ). Serum concentration profiles and pharmacokinetic parameters were similar in patients on hemodialysis, renal transplant recipients and normal children. Elimination half-life was longer in the 9 cyclosporine-treated subjects (108.0+/-13.6 min) than in the other nine (71.2+/-8.3 min; p <0.02). Our finding suggests that, from a pharmacokinetic point of view, DFZ dose adjustment for renal function is not necessary in children with chronic renal failure or after renal transplantation.

New triple screen test for Down syndrome: combined urine analytes and serum AFP

In this study we report a new triple test that combines serum AFP, urine beta-core fragment of hCG, total urine estriol, and maternal age for calculating individual Down syndrome odds in the second trimester. The urine beta-core fragment/estriol ratio was used as a single screening variable. Analyte levels were measured prospectively in 10 Down syndrome cases and 346 normals. Individual Down syndrome odds were calculated by multiplying the product of the Down syndrome likelihood ratios of serum AFP and urine beta-core/estriol levels by the age-related midtrimester risk. The screening efficiency of an algorithm that combines urine beta-core/estriol with maternal age was compared to one that included serum AFP data. A 90% detection rate for Down syndrome was obtained at a 4.65% false positive rate. This was superior to the 75% sensitivity at 5% false positive rate observed when beta-core/estriol and age alone were used. This new triple test has a higher screening efficiency than that generally reported for the traditional serum triple screen and other urine tests, and it also provides information on the risk of neural tube defects. If confirmed in larger trials, the new algorithm could be used as an alternative to the traditional serum triple screen.

Effect of ethnicity on adherence to diabetic regimen

OBJECTIVE

Evaluating the effectiveness of treatment of diabetic patients in our institution led us to seek the relationship between adherence to diabetic regimens and several demographic variables. Of primary importance was ethnicity, which the practitioners believed affected adherence. Other variables researched were: marital status, gender, weight, age, type and duration of diabetes, socioeconomic status, occupation and education.

PATIENTS

Adult diabetic patients (215) seen in the diabetic clinic of a large health maintenance organization who had their diabetes for at least 6 months.

METHODS

Data were collected from interviews and medical records over a two-year period.

RESULTS

Ethnicity, the major test variable, did not show a relationship to adherence. Two variables, gender and weight, showed a trend to significant relationship to adherence. Chi square and t tests were used, depending on the type of data.

CONCLUSIONS

Since there is no difference in adherence between ethnic groups, standardized care protocols are warranted, since they are cost-efficient.

Improved Control of Green Mold of Citrus with Imazalil in Warm Water Compared with Its Use in Wax

The effectiveness of imazalil for the control of citrus green mold (caused by Penicillium digitatum) improved significantly when fruit were treated with heated aqueous solutions of the fungicide as compared with the current commercial practice of spraying wax containing imazalil on fruit. When applied at less than 500 μg·ml^-1 in solutions heated to 37.8°C, control of postharvest green mold of citrus was significantly superior to applications of 4,200 μg·ml^-1 imazalil in wax sprayed on fruit at ambient temperatures. The improvement in imazalil efficacy was obtained with a decrease in fungicide residues on the fruit. Residues of about 3.5 μg·g^-1 imazalil deposited by the application of imazalil in wax reduced the incidence of green mold on lemons from 94.4% among untreated controls to 15.1%, whereas an equal residue deposited by passing fruit through heated aqueous imazalil reduced green mold incidence to 1.3%. Similar differences were found in tests with oranges. Residues of 2 and 3.5 μg·g^-1 imazalil were needed to control the sporulation of P. digitatum on oranges and lemons, respectively. The mode of application of imazalil did not influence control of sporulation. The influence of immersion time, imazalil concentration, and solution temperature on imazalil residues on oranges and lemons was determined in tests using commercial packing equipment, and a model that describes residue deposition was developed. Residues after a 30- or 60-s treatment in heated aqueous imazalil were sufficient to control sporulation, but residues after 15-s treatments were too low and required an additional application of 1,070 μg·ml^-1 imazalil in wax to deposit an amount of imazalil sufficient to control sporulation. An imazalil-resistant isolate of P. digitatum was significantly controlled by heated aqueous imazalil. The incidence of green mold of navel oranges was reduced from 98.8 to 17.4% by treatment in 410 μg·ml^-1 imazalil at 40.6°C for 90 s. However, control of the resistant isolate required imazalil residues on the fruit of 7.9 μg·g^-1, which is within the U.S. tolerance of 10 μg·g^-1 but above the 5 μg·g^-1 tolerance of some countries that import citrus fruit from the United States.

Effect of repeated collection on semen characteristics of alpacas

Semen characteristics of alpacas were studied after repeated collections. Twelve adult males were divided into three groups of four each for semen collection once, twice, or three times every other day. The duration of copulation; volume of ejaculate; pH; motility; sperm concentration (number of sperm/milliliter semen); total number of sperm per ejaculate; and percentages of live, normal, and abnormal spermatozoa were analyzed by regression analysis. Semen color and consistency were analyzed by the chi-square test. Between the first, second, and third ejaculations, there were differences (p < 0.05) in sperm concentration; percentages of normal spermatozoa and abnormal spermatozoa; sperm with abnormal heads and abnormal tails; and consistency (viscous, viscous, and semi-viscous). There were no differences (p > 0.05) in ejaculated volume, percentage of live spermatozoa, pH, percentage of cytoplasmic droplets, and duration of copulation. Some males from which semen was collected on the three-mating schedule ejaculated only seminal plasma during the second and third copulation starting on Day 10 of the study. There were differences between males (p < 0.05) for most of the characteristics studied. In sum, frequency of mating affected some semen characteristics that may be important determinants of the fertility of male alpacas.

American Society of Anesthesiology scoring discrepancies affecting the National Nosocomial Infection Surveillance System: surgical-site-infection risk index rates

The American Society of Anesthesiology (ASA) scoring was performed for the National Nosocomial Infection Surveillance (NNIS) System surgical-site-infection (SSI) risk indexing in 250 prosthetic-joint surgeries. There were ASA scoring discrepancies in 59% of 116 ASA-3 surgeries and 2 out of 10 ASA-3 SSI. The original ASA scoring led to an uncorrected SSI rate of 5.8 per 100 surgeries in the NNIS risk group 0; with corrected ASA scores, the rate was 4.5 per 100 surgeries.

Inducible overexpression of oat arginine decarboxylase in transgenic tobacco plants

To test the possible interaction of polyamines in plant growth responses, transgenic tobacco plants containing the Avena sativa L. (oat) arginine decarboxylase (ADC) gene under the control of a tetracycline-inducible promoter were generated. Inducible overexpression of oat ADC in transgenic tobacco led to an accumulation of ADC mRNA, increased ADC activity and changes in polyamine levels. Transgenic lines, induced during vegetative stage, displayed different degrees of an altered phenotype, the severity of which was correlated with putrescine content. These phenotypic changes were characterized by short internodes, thin stems and leaves, leaf chlorosis and necrosis, as well as reduced root growth. This is the first report to show altered phenotypes as a consequence of polyamine changes under tetracycline-induction in in vivo conditions. Interestingly, overexpression of oat ADC in tobacco resulted in similar detrimental effects to those observed by ADC activation induced by osmotic stress in the homologous oat leaf system. In the context of the role of specific polyamines in plant growth and development, the present results indicate that activation of the ADC pathway leading to high levels of endogenous putrescine (or its catabolytes) is toxic for the vegetative growth of the plant. In contrast, no visible phenotypic effects were observed in flowering plants following tetracycline induction. Further characterization of the different transgenic lines may shed light on the action of specific polyamines in different plant developmental processes.

Effects of hypoxia and hyperoxia on lung prostaglandin E1 metabolism

Exposure to hypoxia (10% O2 for 5 to 7 days) results in increased survival and decreased pulmonary toxicity of adult rats subsequently exposed to hyperoxia (> 97% O2). These experiments tested whether hypoxia preexposure minimized the decrease in lung metabolism of prostaglandin E1 (PGE1), a vasoactive and antiinflammatory prostaglandin, caused by hyperoxia. Transpulmonary PGE1 clearance was measured as fractional metabolism of PGE1 (2 microM to 30 microM) infused during a 45-second period in an isolated, buffer-perfused rat lung preparation after exposure of rats to one of the following conditions: (1) hyperoxia (> 97% O2 for 48 hours), (2) hypoxia (10% O2 for 120 hours), or (3) hypoxia followed by hyperoxia. Hyperoxia exposure decreased both lung PGE1 metabolism and lung prostaglandin dehydrogenase activity (PGDH). Hypoxia also decreased lung PGE1 metabolism but, in contrast, increased lung PGDH activity. Hypoxia preexposure did not prevent the depression of PGE1 metabolism or PGDH activity caused by hyperoxia, which indicates that survival in hyperoxia did not depend on lung PGE1 metabolism. Hypoxia itself impaired transpulmonary metabolism of PGE1 despite increasing PGDH activity, which suggests possible interference with substrate delivery.