A first implementation and evaluation of the IEEE 802.11aa group addressed transmission service

The IEEE 802.11aa Task Group has recently standardized a set of mechanisms to efficiently support video multicasting, namely, the Group Addressed Transmission Service (GATS). In this article, we report the implementation of these mechanisms over commodity hardware, which we make publicly available, and conduct a study to assess their performance under a variety of real-life scenarios. To the best of our knowledge, this is the first experimental assessment of GATS, which is performed along three axes: we report their complexity in terms of lines of code, their effectiveness when delivering video traffic, and their efficiency when utilizing wireless resources. Our results provide key insights on the resulting trade-offs when using each mechanism, and paves the way for new enhancements to deliver video over 802.11 Wireless LANs.

Recommendations of the GARIN group for managing non-critically ill patients with diabetes or stress hyperglycaemia and artificial nutrition

BACKGROUND & AIMS

By means of this update, the GARIN working group aims to define its position regarding the treatment of patients with diabetes or stress hyperglycaemia and artificial nutrition. In this area there are many aspects of uncertainty, especially in non-critically ill patients.

METHODS

Bibliographical review, and specific questions in advance were discussed and answered at a meeting in the form of conclusions.

RESULTS

We propose a definition of stress hyperglycaemia. The indications and access routes for artificial nutrition are no different in patients with diabetes/stress hyperglycaemia than in non-diabetics. The objective must be to keep pre-prandial blood glucose levels between 100 and 140 mg/dl and post-prandial levels between 140 and 180 mg/dl. Hyperglycemia can be prevented through systematic monitoring of capillary glycaemias and adequately calculate energy-protein needs. We recommend using enteral formulas designed for patients with diabetes (high monounsaturated fat) to facilitate metabolic control. The best drug treatment for treating hyperglycaemia/diabetes in hospitalised patients is insulin and we make recommendations for adapt the theoretical insulin action to the nutrition infusion regimen. We also addressed recommendations for future investigation.

CONCLUSIONS

This recommendations about artificial nutrition in patients with diabetes or stress hyperglycaemia can add value to clinical work.

Alcohol administration blocks stress-induced impairments in memory and anxiety, and alters hippocampal neurotransmitter receptor expression in male rats

Chronic exposure to stress has many deleterious effects on behavior, which can often lead to self-medication with anxiolytics, antidepressants, or alcohol. We determined the effects of alcohol administration following a stressor on established behavioral, physiological, and neural responses to stress. Male Sprague-Dawley rats received: No alcohol/No stress (CON), Alcohol alone (ALC), Stress alone (STR), or Stress plus Alcohol (STR+ALC). For seven consecutive days, two cohorts received an oral dose of 2.0 g/kg of either 20% ethanol or saline. In Cohort 1, behavioral testing began after the final treatment (day-8). Memory was tested using the object recognition (OR) and Y-maze, anxiety on the plus maze, and depression on the forced swim task. Memory on OR and Y-maze tasks was impaired in the ALC and STR groups. This deficit was reversed in the STR+ALC group, which performed not differently from the CON group. Stress alone was associated with increased anxiety, which was alleviated with alcohol treatment. No treatment effects were found in the forced swim task. In Cohort 2, hippocampal GABAα4 was upregulated in the STR+ALC group and GluN2B was upregulated in the ALC and STR+ALC groups. The STR+ALC group in Cohort 1 showed enhanced corticosterone levels after forced swim. The STR+ALC group in Cohort 2 showed increased corticosterone levels on day-1 of treatment and a habituation by day-7. In conclusion, this study found a reversal of stress-induced deficits in cognition and anxiety when alcohol was given post-stress, and changes in neurotransmitter receptor expression may contribute to these behavioral effects.

Applicability, safety and efficiency of outpatient treatment in uncomplicated diverticulitis

BACKGROUND

In most cases of diverticulitis, inflammation is mild, and the only treatment required is a clear liquid diet and antibiotics. Until recently, patients were given this treatment as inpatients with the consequent expenditure of resources. The aim of this study was to assess the safety and efficacy of an outpatient treatment protocol with oral antibiotics in selected patients with uncomplicated acute diverticulitis in comparison with inpatient intravenous treatment.

METHODS

We conducted a prospective non-randomized study between January 2007 and December 2009. We included all patients diagnosed with uncomplicated acute diverticulitis, at the Emergency Department of the University General Hospital of Elche. We compared the efficacy, safety and costs of hospital treatment with intravenous antibiotics and outpatient treatment with oral antibiotics. Seventy-six patients were included in the study. Forty-four of them underwent intravenous treatment with Metronidazole 500 mg/8 h + Ciprofloxacin 400 mg/12 h (hospital treatment group) and 32 took oral antibiotics Metronidazole 500 mg/8 h and Ciprofloxacin 500 mg/12 h (outpatient group).

RESULTS

Outpatient treatment is viable in almost 95 % of those patients suffering from uncomplicated acute diverticulitis. Treatment was effective in resolving inflammation, and there were no complications in the majority of cases (94 %). Only 2 patients (6 %) required admission after outpatient treatment. The results further reflect complications and relapse rates similar to those of patients admitted to hospital and treated with intravenous antibiotics. There are no significant statistical differences (p = 0.86) between inpatients and outpatients. It is possible to save approximately 1,600 € per patient with outpatient treatment (p < 0.05).

CONCLUSIONS

Outpatient treatment has demonstrated a safety and efficiency similar to inpatient treatment, producing an important reduction in expenses and medical resources.

Association of PHB 1630 C>T and MTHFR 677 C>T polymorphisms with breast and ovarian cancer risk in BRCA1/2 mutation carriers: results from a multicenter study

BACKGROUND

The variable penetrance of breast cancer in BRCA1/2 mutation carriers suggests that other genetic or environmental factors modify breast cancer risk. Two genes of special interest are prohibitin (PHB) and methylene-tetrahydrofolate reductase (MTHFR), both of which are important either directly or indirectly in maintaining genomic integrity.

METHODS

To evaluate the potential role of genetic variants within PHB and MTHFR in breast and ovarian cancer risk, 4102 BRCA1 and 2093 BRCA2 mutation carriers, and 6211 BRCA1 and 2902 BRCA2 carriers from the Consortium of Investigators of Modifiers of BRCA1 and BRCA2 (CIMBA) were genotyped for the PHB 1630 C>T (rs6917) polymorphism and the MTHFR 677 C>T (rs1801133) polymorphism, respectively.

RESULTS

There was no evidence of association between the PHB 1630 C>T and MTHFR 677 C>T polymorphisms with either disease for BRCA1 or BRCA2 mutation carriers when breast and ovarian cancer associations were evaluated separately. Analysis that evaluated associations for breast and ovarian cancer simultaneously showed some evidence that BRCA1 mutation carriers who had the rare homozygote genotype (TT) of the PHB 1630 C>T polymorphism were at increased risk of both breast and ovarian cancer (HR 1.50, 95%CI 1.10-2.04 and HR 2.16, 95%CI 1.24-3.76, respectively). However, there was no evidence of association under a multiplicative model for the effect of each minor allele.

CONCLUSION

The PHB 1630TT genotype may modify breast and ovarian cancer risks in BRCA1 mutation carriers. This association need to be evaluated in larger series of BRCA1 mutation carriers.

In vitro effect of calcium dobesilate on oxidative/inflammatory stress in human varicose veins

AIM

To determine whether calcium dobesilate can act in chronic venous insufficiency by similar antioxidant, anti-inflammatory mechanisms as in diabetic retinopathy.

METHODS

Calcium dobesilate was tested in vitro for its protective action against oxidative/inflammatory stress in human varicose veins. Varicose greater saphenous veins were obtained from 14 patients (11 men, 3 women) aged 53-65 years. Oxidative stress was induced exogenously in the vein segments, with the phenazine methosulphate (PMS)/NADH couple. Total antioxidant status (TAS) and malondialdehyde (MDA) contents were used as markers of oxidative stress.

RESULTS

Calcium dobesilate significantly prevented oxidative disturbances in the micromolar range. PMS/NADH-dependent TAS decrease was fully prevented with IC(50) = 11.4 ± 2.3 µmol/L (n = 6 veins), whereas MDA increase was fully prevented with IC(50) = (102 ± -3) µmol/L (n = 6 veins). Calcium dobesilate acted quali- and quantitatively like rutin, the reference compound. Comparison with pharmacokinetic data suggests that calcium dobesilate can act at therapeutic concentrations.

CONCLUSION

Calcium dobesilate protected human varicose veins against oxidative stress in vitro at levels that correspond to therapeutic concentrations. Further studies are required to investigate whether a similar action is found in varicose veins from patients orally treated with calcium dobesilate.

Alternating Polistes-Vespula venom immunotherapy: a therapeutic strategy to resolve a diagnostic deficiency

BACKGROUND

In Mediterranean regions, double sensitization to Polistes and Vespula species is frequent in patients reacting to an unidentified wasp sting. Since both genera are present, it is often difficult to determine which insect is responsible and, consequently, select venom for immunotherapy. When a specific diagnosis cannot be made, a new therapeutic strategy should be undertaken.

METHODS

We performed a case-control study in which 37 patients who were allergic to venom from Vespula and Polistes species received a 3-year schedule of alternating immunotherapy. Twenty monosensitized patients (10 to Vespula and 10 to Polistes) received conventional venom immunotherapy (VIT) during the same period. All 57 patients received the same number of injections. The effectiveness of VIT was assessed by means of re-sting, which was performed yearly. Serum specific immunoglobulin (Ig) E and IgG4 were also studied,

RESULTS

All the cases tolerated all the stings. One control patient developed a mild systemic reaction after the first-year Vespula sting but tolerated subsequent re-stings. Both cases and controls reached significant changes in levels of IgE and IgG4 after VIT (P < .04 at minimum). The cases developed a response as expected, although this was less intense than in the control group. In the Polistes control subgroup, sIgE to Polistes decreased to under baseline levels, after a marked initial increase; this decrease was not observed in the Vespula subgroup.

CONCLUSION

An alternating VIT strategy is appropriate and provides protection to patients sensitized to Vespula and Polistes.

CARMEN

Even though current mesh networks are mostly WiFi-based, future networks are expected to be highly heterogeneous. Motivated by this expectation, CARMEN (CARrier grade MEsh Networks) project focuses on developing a heterogeneous mesh backhaul to provide carrier-grade (voice, video and data) services. This demo presents resource management and abstraction in CARMEN architecture, which allow meeting the challenges of heterogeneous radio access.

CEN EN13606 normalisation framework implementation experiences

Since the approval of the CEN EN13606 norm for the electronic health record communication, a growing interest around the application of this specification has emerged. The main objective of the norm is to serve as a mechanism to achieve the semantic interoperability of clinical data. This will require an effort to use common terminologies, to normalise the clinical knowledge domain and to combine all these formalisations with the existing information systems. This paper presents a methodology and developed tools to reach the seamless semantic interoperability of health data in legacy systems and several study cases where the developed framework has been applied.

Development of the dynamic structure (force lines) of the middle ear ossicles in human foetuses

OBJECTIVES

To study the ontogenic development of the organisation of the human middle ear ossicles structure.

MATERIAL AND METHODS

46 human temporal bones of ages varying from 32 days post-conception to newborns.

RESULTS

The development of the structural organisation of the malleus begins at 16 weeks via two cortical fascicles situated in the neck; at 21 weeks they extend towards the head, at 23 weeks to the lateral process and at 24 weeks to the handle. In the handle, the force lines are transmitted via three cardinal fascicles, two of them via the cortical fascicle and one via the centre, which starts after 29 weeks' development and is consolidated after 31 weeks. In the incus the force lines start at 16 weeks via two cortical fascicles situated in the long process, which progressively extend in a rostro-caudal direction between 17 and 20 weeks. At 21 weeks they occupy the whole extension of the long process and at 22 weeks the fusion of both cortical fascicles begins. From 30 weeks onwards it is strengthened by the crossing of bone trabeculae from one cortical to another. Two fascicles come out of the incus body, surrounding the medullary cavity and going in the direction of the short process. In the beginning, the stapes have two cortical fascicles in their crura. The remodelling process makes the internal cortical fascicle disappear and after 31 weeks all the force lines run through the external cortical fascicle. The tympanic membrane of the stapes footplate undergoes a remodelling process and after 28 weeks bony trabeculae are deposited. In newborns (40 weeks), the ossicles' structure is cavitary and has not been completed. The fan-shaped trabecular fascicle, which starts in the articular facets of the malleus and the incus, still has to develop.

[Pilot study for the inclusion of the portfolio of the family medicine specialist book in training]

BACKGROUND

The Spanish Family Medicine National Commission is proposing a new portfolio-type Specialist Training Book (STB).

OBJECTIVE

To pilot its contents, structure, and implementation strategies.

DESIGN

Cross-sectional, descriptive study.

SETTING

A Provincial Family Medicine Teaching Unit.

PARTICIPANTS

Twenty-eight tutors and 36 residents.

METHODS

For 9 months the participants conducted a training assessment on diverse areas of competence by means of tasks at work. Tutors recorded information on the quality of reflection achieved by residents and the tasks they performed by means of the card model proposed in the STB. Residents filled in an ad hoc survey. A univariate analysis of quantitative data was conducted.

RESULTS

Thirty-three surveys were received from residents; 21 tutors handed in 67 evaluation reports (average: 3 per tutor). They dealt with all the areas of competence, particularly those of communication, teaching, and ethics. Tasks most used were clinical sessions, critical incidents and video-recording. Both tutors and residents thought that the new method could be useful for reflecting on clinical practice, understanding their own areas of competence better and for strengthening the tutor-trainee relationship, especially if some suggestions to improve its practical use and reduce time and effort involved were taken into account.

CONCLUSIONS

The new STB in its current version or with some modifications is a useful tool for residents' training assessment and is probably accepted well in our ambit.

Predicting patients at high-risk of systemic reactions to cluster allergen immunotherapy: a pilot prospective observational study

OBJECTIVE

The purpose of this study was to identify factors associated with increased risk of adverse systemic reactions to cluster allergen immunotherapy and to create a preliminary predictive clinical model.

METHODS

In a prospective observational study, the tolerance of 611 patients with seasonal respiratory diseases who were receiving cluster immunotherapy was monitored and all systemic reactions were recorded. Associations between potential prognostic factors (sex, age, respiratory disease, severity, duration of disease, previous immunotherapy, nonseasonal symptoms, skin prick test, total immunoglobulin (Ig) E, specific IgE, treatment schedule, allergenic composition, batch, date of treatment, habitat, place of residence) and systemic reactions were estimated. Multivariate stepwise logistic regression analysis was used to build a predictive clinical model and estimate the probability of systemic reactions to cluster immunotherapy.

RESULTS

Sixty-five patients (10.6%) suffered systemic reactions. Only 7 independent risk factors were retained in the final model: age over 14 years (odds ratio [OR], 2.6), previous immunotherapy (OR, 0.3), skin prick test positive to Chenopodium album (white goosefoot) (OR, 3.0), elevated specific IgE to grass pollen (OR, 2.3), elevated specific IgE to olive pollen (OR, 4.1), olive pollen 100% composition (OR, 2.6) and treatment schedule (OR, 1, 1.6 or 7.1, depending on the cluster immunotherapy schedule).

CONCLUSIONS

This predictive model, derived from simple clinical variables, has excellent ability to assess individual risk of suffering systemic reactions to cluster allergen immunotherapy. Detecting high-risk patients can help clinicians to prevent and eliminate many severe adverse reactions to cluster immunotherapy.

Degree of olive pollen exposure and sensitization patterns. Clinical implications

BACKGROUND

Very high levels of exposure to olive pollen in the south of Spain lead to differential allergen sensitization profiles. Therefore, new approaches to allergen standardization, diagnosis, and vaccination are necessary.

METHODS

Quantification of minor allergens in extracts, component-resolved patient diagnosis, and IgG4 individual allergen responses were used to evaluate new strategies in the management of olive pollen allergy.

RESULTS

Allergen variability observed between different olive cultivars can be used to identify suitable allergen sources that can be combined to yield consistent allergen extracts for diagnosis and immunotherapy. Component-resolved diagnosis can provide a better patient classification. IgG4 levels to major allergens increase significantly, whereas specific IgG4 to minor allergens does not seem to increase, at least during the early phases of immunotherapy.

CONCLUSION

Patients exposed to extreme olive pollen levels display a different severity of allergy from those exposed to normal levels, which makes it necessary to follow a different clinical approach. The use of component-resolved diagnosis, better standardized allergen extracts, and new efficacy monitoring techniques will lead to a significant improvement in the management of olive allergy disease.

Is anal endosonography useful in the study of recurrent complex fistula-in-ano?

INTRODUCTION

performing anal endosonography in complex fistula-in-ano allows us to design a personalized surgical strategy in each case, thereby improving results. However, there are doubts in the literature as to its utility in recurrent complex fistulas. The aim of this study was to compare the utility of anal ultrasonography in the study of primary versus recurrent complex fistula-in-ano.

PATIENTS AND METHOD

prospective study of patients diagnosed and treated for complex fistula-in-ano. Physical examination and anal ultrasonography provided data on primary track, internal opening, horseshoe extension and the presence of secondary tracks or cavities in a protocol designed specifically for the study. These assessments were subsequently contrasted with operative findings.

RESULTS

we included 35 patients, 19 (54.3%) with primary complex anal fistulas and 16 (45.7%) with recurrent fistulas. According to the operative findings, fistulas were classified as high transsphincteric in 28 patients (80%), suprasphincteric in 6 (17.1%) and extrasphincteric in one patient (2.9%), with no differences between groups. Physical examination correctly classified 28 of the 35 fistulous tracks, in contrast to the 32 (91.4%) correctly described on ultrasonography (80%). We did not find any statistically significant differences between the primary and the recurrent fistula groups with regard to sensibility, positive predictive value and accuracy of the anal ultrasonography for any of the parameters studied.

CONCLUSION

the accuracy of anal ultrasonography does not decrease in recurrent complex fistula-in-ano.

Aortic arch abnormality in a patient with Klippel-Feil syndrome

We present a case of a 43-year-old female with headaches, progressive paresthesias of the upper extremities, and vertigo. Ultrasonography could not visualize the left internal carotid artery (ICA). Magnetic resonance imaging (MRI) showed complete fusion of the C5, C6, and C7 levels, representing Klippel-Feil deformity. Angiography showed a unique abnormality of the aortic arch with complete absence of the left ICA. An embryologic defect associated with this type of abnormality is proposed, with defects of development of the third aortic arch and the aortic sac secondarily.

Prevalence and incidence of gastroduodenal ulcers during treatment with vascular protective doses of aspirin

BACKGROUND

Aspirin is valuable for preventing vascular events, but information about ulcer frequency is necessary to inform risk-benefit decisions in individual patients.

AIM

To determine ulcer prevalence and incidence in a population representative of those given aspirin therapy and evaluate risk predictors.

METHODS

Patients taking aspirin 75-325 mg daily were recruited from four countries. Exclusions included use of gastroprotectant drugs or other non-steroidal anti-inflammatory drugs. We measured point prevalence of endoscopic ulcers, after quantitating dyspeptic symptoms. Incidence was assessed 3 months later in those eligible to continue (no baseline ulcer or reason for gastroprotectants).

RESULTS

In 187 patients, ulcer prevalence was 11% [95% confidence interval (CI) 6.3-15.1%]. Only 20% had dyspeptic symptoms, not significantly different from patients without ulcer. Ulcer incidence in 113 patients followed for 3 months was 7% (95% CI 2.4-11.8%). Helicobacter pylori infection increased the risk of a duodenal ulcer [odds ratio (OR) 18.5, 95% CI 2.3-149.4], as did age >70 for ulcers in stomach and duodenum combined (OR 3.3, 95% CI 1.3-8.7).

CONCLUSIONS

Gastroduodenal ulcers are found in one in 10 patients taking low-dose aspirin, and most are asymptomatic; this needs considering when discussing risks/benefits with patients. Risk factors include older age and H. pylori (for duodenal ulcer).

La gastrostomía endoscópica percutánea. Realidad en la práctica nutricional clínica intra y extrahospitalaria

BACKGROUND

This study aimed to review our experience during 8 years in the use of percutaneous endoscopic gastrostomy (PEG) and its application in home enteral nutrition (HEN).

MATERIAL

We studied 207 patients (56 women and 151 men) who had undergone a PEG from the beginning of 1994 to the end of 2002 as they needed prolonged enteral nutrition (> 4 weeks). In those cases in which home enteral nutrition was programmed, the patients/relatives were trained in the techniques and care of the PEG and EN, and the control was done through the nutrition out-patient clinic.

RESULTS

Mean duration time of the PEG was 640 days and 175 patients (84.6%) needed PEG for more than 60 days and 135 for more than 6 months. Mean calorie supply was 1,730 +/- 288 Kcal/day. Administration mode was by intermittent infusion due to seriousness in 162 cases and continuous infusion through volemetric pump in 45 patients. In 2 patients with hyperemesis gravidarum, percutaneous endoscopic gastrojejunostomy (PEGJ) was done in the 3rd and 4th month of pregnancy, the pregnancy finishing successfully by vaginal delivery. Performance of PEG facilitated hospital discharge and programming of home enteral nutrition in 195 patients (94%). The most frequent complications were gastrostomy infection that occurred in 41 patients and the appearance of granuloma in the ostomy in 34 cases. Only one patient died in direct relationship due to peritonitis after PEG.

CONCLUSION

Our study includes the advantages of PEG as an enteral nutrition technique, permitting the establishment of a home enteral nutrition program with limited incidence of complications and very low mortality.

[Manometric factors associated with recurrence in botulinum toxin treatment for chronic anal fissure]

INTRODUCTION AND AIM

To evaluate the effectiveness of botulinum toxin in the treatment of chronic anal fissure after long-term follow-up and establish the manometric factors related to recurrence.

PATIENTS AND METHOD

We performed a prospective study in 50 consecutive patients with chronic anal fissure who were treated with 25 U botulinum toxin injected into the internal sphincter. Clinical and manometric parameters were recorded until the fourth year of follow-up.

RESULTS

There was a tendency to progressive recurrence over time (54% at 4 years) associated with manometric factors indicating hyperexcitability of the internal anal sphincter (persistently elevated mean resting pressure, percentage of time with slow waves, and number of patients or percentage of time with ultra-slow waves after treatment).

CONCLUSIONS

Treatment of chronic anal fissure with botulinum toxin leads to long-term cure in less than 50% of patients. In patients with manometric factors related to recurrence, this treatment is insufficient for definitive cure.

Long-term results of botulinum toxin for the treatment of chronic anal fissure: prospective clinical and manometric study

BACKGROUND

The aim of this prospective trial was to analyse the effectiveness and morbidity of chemical sphincterotomy in the treatment of chronic anal fissure after a 3-year follow-up.

METHODS

One hundred consecutive patients with chronic anal fissures were treated by chemical sphincterotomy with 25 U botulinum toxin injected into the internal sphincter. Clinical and manometric results were recorded.

RESULTS

No major complications were found; initial incontinence at the 2-month review (6%) spontaneously reversed at 6 months. There was a tendency of progressive recurrence over time, with an overall healing after 3 years of 47%. We found a group of patients with clinical (symptoms longer than 12 months and presence of a sentinel pile before treatment) and manometric factors (persistently elevated mean resting pressure, percentage of time with slow waves, and number of patients or percentage of time with ultra slow waves after treatment) associated with a higher recurrence of anal fissures.

CONCLUSION

Since it avoids the greater risk of incontinence associated with surgical sphincterotomy, we recommend the use of botulinum toxin as the first therapeutic approach for patients with chronic anal fissure and risk factors for incontinence; despite the higher rate of recurrence associated with this treatment. In patients with factors related to recurrence, re-injection with higher doses of botulinum toxin or complementary medical-surgical treatment should be considered.

Pollen allergy in Cordoba city: frequency of sensitization and relation with antihistamine sales

The occurrence of symptoms in pollen allergy patients in urban areas may be affected by local environmental factors such as sources of pollution, natural and ornamental vegetation, local architecture impeding dispersion, etc. The aim of this study was to analyse the frequency of sensitization in pollen allergy patients and the relationship with antihistamine sales. For this study, a large number of clinical records, together with pharmaceutical and pollen data, were collected between 1999 and 2001 in the city of Córdoba, in the south of the Iberian Peninsula. Differences were observed in the symptoms suffered by pollen allergy patients in different areas of the city due to varying local emission of both biological and non-biological particles. Temporal distribution of symptoms over the three study years was influenced by meteorological factors, especially rainfall patterns; higher water supply to plants was associated with increased airborne pollen concentrations. Air pollution might be one of the main factors affecting the distribution of pollen allergy patients within the city. Recent years have seen a worsening of symptoms and increased sensitization to urban species such as plane-trees.

Benefits of cognitive-motor intervention in MCI and mild to moderate Alzheimer disease

OBJECTIVE

To evaluate the efficacy of a cognitive-motor program in patients with early Alzheimer disease (AD) who are treated with a cholinesterase inhibitor (ChEI).

METHODS

Patients with mild cognitive impairment (MCI) (12), mild AD (48), and moderate AD (24) (Global Deterioration Scale stages 3, 4, and 5) were randomized to receive psychosocial support plus cognitive-motor intervention (experimental group) or psychosocial support alone (control group). Cognitive-motor intervention (CMI) consisted of a 1-year structured program of 103 sessions of cognitive exercises, plus social and psychomotor activities. The primary efficacy measure was the cognitive subscale of the AD Assessment Scale (ADAS-cog). Secondary efficacy measures were the Mini-Mental State Examination, the Functional Activities Questionnaire, and the Geriatric Depression Scale. Evaluations were conducted at 1, 3, 6, and 12 months by blinded evaluators.

RESULTS

Patients in the CMI group maintained cognitive status at month 6, whereas patients in the control group had significantly declined at that time. Cognitive response was higher in the patients with fewer years of formal education. In addition, more patients in the experimental group maintained or improved their affective status at month 12 (experimental group, 75%; control group, 47%; p = 0.017).

CONCLUSIONS

A long-term CMI in ChEI-treated early Alzheimer disease patients produced additional mood and cognitive benefits.

S-100 protein immunoreactivity in the upper eyelid of the sheep Ovis aries

The aim of this work was to analyse the distribution pattern of S-100-immunoreactive elements in the upper eyelid of the sheep. This pattern may be of importance regarding the diagnosis and prognosis of eyelid tumours that are linked to deregulation of S-100 gene expression. Thirty upper eyelids taken from 15 adult male Ovis aries were studied by means of the peroxidase-antiperoxidase method for light microscopy. S-100-immunopositive cells were found in the eyelid edge. S-100-immunopositive steams and thinner fibres were found throughout the eyelid. These nerve processes typically were denser around glands, hair follicles and blood vessels. S-100-immunopositive elements may play a role as neuromodulator and also in the development of the vegetative innervation of the epithelium and its derivatives.

Open versus closed day-case haemorrhoidectomy: is there any difference? Results of a prospective randomised study

BACKGROUND AND AIMS

Nowadays there is still controversy as to whether open or closed haemorrhoidectomy is the surgical treatment of choice for haemorrhoidal pathology.

PATIENTS AND METHODS

We carried out a randomised prospective study in the Day Surgery Unit comparing 100 patients undergoing Milligan-Morgan haemorrhoidectomy (group A) versus 100 patients undergoing Ferguson haemorrhoidectomy (group B) for symptomatic haemorrhoids, in whom medical treatment or rubber band ligation had failed.

RESULTS

Characteristics of the population were: mean age 43.5 years, with predominance of males, 123 vs. 77; 88% ASA I-II.

CLINICAL PRESENTATION

95% rectal bleeding; 87.5% third-fourth degree. The anaesthetic technique of choice was local anaesthesia plus sedation in 180 patients (90%). Length of surgery: 24 min (group A) and 30 min (group B) (p=n.s.). Resection of three haemorrhoidal cushions was done in 87.5% of cases. There were no re-operations or re-admissions after discharge. Symptomatic recurrence, stenosis and incontinence were not found during the follow-up of the first year. Postoperative pain during the first postoperative week was greater in the open haemorrhoidectomy group, but the difference was statistically significant (p<0.05) only during bowel movements. There was complete healing in 40% of the patients in group A and 90% of those in group B (p<0.05) after 1 month. After 1 year, the results and complications were similar in both groups (p=n.s.).

CONCLUSIONS

Closed haemorrhoidectomy gives better results in terms of pain and healing than open haemorrhoidectomy, whereas recurrence and complications are similar after 1 year.

Clinical features of ten cases of osteopoikilosis

A retrospective study was carried out of the ten cases of osteopoikilosis seen at this Orthopedic Unit over a 15-year period in order to determine the reasons why patients seek consultation, preliminary diagnosis, and associated lesions. Eight patients consulted for problems not related to the locomotor apparatus, and diagnosis was by chance; the other two presented joint pain. The preliminary diagnosis was osteoblastic metastasis in five patients and osteopoikilosis in the other five. None of the patients displayed skin or visceral involvement, but three presented bone alterations. Definitive diagnosis was made by measurement of biochemical markers of bone remodeling, radiography of both hands, and bone scan. Bone biopsy was performed in one case. Although rare, the radiographic symptoms of osteopoikilosis are sufficiently specific to avoid false diagnoses, which may give rise to rigorous and expensive studies for other important disorders.

Targeted cybridization in citrus: transfer of Satsuma cytoplasm to seedy cultivars for potential seedlessness

CMS (cytoplasmic male sterility) can be controlled by the mitochondrion genome in higher plants, including Satsuma mandarin. Somatic fusion experiments in citrus combining embryogenic callus protoplasts of one parent with leaf protoplasts of a second parent often produce cybrid plants of the leaf parent, a phenomenon occurring most often with interspecific fusion combinations. In an attempt to practically exploit this cybridization phenomenon, we conducted somatic fusion experiments combining embryogenic suspension-derived protoplasts of Satsuma mandarin, Citrus unshiu Marc. cv. Guoqing No. 1 (G1), a male-sterile cultivar, with leaf protoplasts of other seedy types--Hirado Buntan Pink pummelo (HBP) [Citrus grandis (L.) Osbeck], Sunburst mandarin (C. reticulata Blanco), Orie Lee hybrid (C. reticulata cv. Clementine x Murcott tangor), and Murcott tangor [C. reticulata x C. sinensis (L.) Osbeck], respectively--in an attempt to generate seedless cybrids by the targeted transfer of CMS. The genetic identities of regenerated plants from all four parental combinations were determined by flow cytometry, SSR, CAPS (or PCR-RFLP), RFLP, and chloroplast-SSR analyses. Regenerated plants from the first three parental combinations were diploids, and the cybrid nature of G1 + HBP with the mitochondrion genome from G1 and the chloroplast genome from HBP was confirmed, whereas the cybrid nature of the remaining two combinations was difficult to confirm because of the close phylogenetic relatedness of both fusion parents, as expected. Plants from G1 + Murcott were confirmed as tetraploid somatic hybrids. This is the first report of targeted citrus cybrid production by symmetric fusion with male-sterile Satsuma as the callus parent and other seedy cultivars as the leaf parents.

EVALUATION OF FUNCTIONAL IMPROVEMENT IN OLDER PATIENTS WITH COGNITIVE IMPAIRMENT, DEPRESSION AND/OR DELIRIUM ADMITTED TO A GERIATRIC CONVALESCENCE HOSPITALIZATION UNIT

Cognitive impairment, depression and delirium are problems of high prevalence in older patients. The geriatric convalescence unit (GCU) is a hospitalization facility offering an interdisciplinary geriatric intervention program that may be more appropriate for these patients. This study intended to analyze the functional improvement (FI) in older patients with cognitive impairment, depression and/or delirium admitted to a GCU. A group of 107 patients received specific nurse care, habitually performed in GCU and they also were included in a rehabilitation program. Cognitive impairment, depression and delirium were diagnosed according to standardized protocols. The analyzed variables were: age, functional status (Barthel index) before admission (BBA), at admission (BA) and at discharge(BD), diagnostic categories, cognitive function (mini mental state examination: MMSE) and post-discharge destination. The corrected Heinemann index (CHI) was used to evaluate FI obtained during GCU-stay, where CHI = 100 x (BD-BA)/(BBA-BA), and the efficiency index(El) was used to analyze the relationship between FI and the length of stay in the GCU,where El = (BD-BA)/(days in GCU). According to CHI, patients were divided in three groups. Group I: CHI = 0 or negative (patients who lost functional capacity during hospitalization,those who died or were transferred to hospital owing to acute deterioration. Group II: CHI < 35 % (high FI). Mean age was 77.6 +/- 9.1 years, the diagnostic categories were: fractures/orthopedics 49 (45.7 %), neurological 27(25.2 %), pulmonary/cardiologic 6 (5.6 %) and other cases 25 (23.3 %). Mean MMSE and BA scores were 16.9 +/- 9.4 and 29.6 +/- 18.9, respectively. Post-discharge destinations were:63 patients (58.8 %) returned home, 28 (26.1 %) were definitively institutionalized, 11 (10.2%) died and finally 5 (4.6 %) were transferred to acute care hospital. In-Group I, there were 35 patients (32.7 %) with a mean value of the El = 0.12 +/-1.1; in Group II, 13 (12.1 %) and 0.26 +/- 0.38; in Group III, 59 (55.1 %) and 0.94 +/- 0.97, respectively. In spite of the presence of cognitive impairment, depression and/or delirium, a high proportion of patients (67.2 %)obtained a significant improvement in their functional capacity.35 % (moderate FI). Group III: CHI >/=

Primary anaplastic large cell lymphoma of the testis

Anaplastic large cell lymphoma (ALCL) was first described by Stein et al. in 1985, at that time neoplastic cells were labeled by the monoclonal antibody CD30. ALCL was included as a differentiate entity in the reviewed Kiel and REAL classification. ALCL carries the t (2; 5) (p23; q35) translocation; the absence of ALK kinase from normal lymphoid cells indicates that immunohistochemical expression of ALK is specific for the (2; 5) translocation. This disease is characterized by a diffuse proliferation of large anaplastic cells with kidney-shaped/horse-shoe nuclei. A distinguishing feature is a perinuclear eosinophilic region that represents a prominent Golgi apparatus. These cells are named hallmark-cells being almost pathognomonic. Immunohistochemically the most important features are that tumor cells consistently express CD30 and EMA on the cell membrane and in the Golgi region, while ALK immunostaining is usually both, cytoplasmic and nuclear. To our knowledge only two cases of primary ALCL of the testis have been reported. Hereby we present a case of a typical ALCL expressing ALK and CD30, which presented with subcutaneous nodules and bilateral testicular mass, without systemic involvement.

Prospective safety study of immunotherapy administered in a cluster schedule

Cluster immunotherapy is becoming an alternative to conventional IT due to its shorter schedule, but the safety of such schedule is still controversial. At present, only few studies assess the risk of immunotherapy in a prospective manner, in well-controlled patients, using the same extract and intending to evaluate a single schedule. The aim of the present study is to evaluate the safety of a cluster immunotherapy administration regimen. A total of 91 outpatients (41 male and 50 female), with a mean age of 25 years old (range: 16-50) were included. Sixty-one patients were diagnosed mild to moderate asthma and 30 rhinoconjunctivitis. Forty-six of the enrolled patients were sensitised to pollen (Lolium perenne and/or Olea europea), 38 to Dermatophagoides pteronyssinus and 7 to Alternaria alternata. Patients received specific immunotherapy following a five-week cluster schedule. It was considered as a preseasonal treatment, that is, it was accomplished before olive and grass initial pollinating months in this area (March--April). A total 1029 injections were administered during the induction phase. Adverse reactions were assessed and classified according to the EAACI criteria. The average number of visits to maximum dose was 6 (range 2-10), and 70 patients (77%) reached the maximum between 5-7 visits. In each of the visits an average of 2 (range 1-3) injections were administered. Eighty-one of the 91 initially enrolled patients (89%) completed the cluster schedule. The total number of reactions were 47 (24 local and 23 systemic). No fatal reactions were observed. Since the total number of administered injections was 1029, the relative frequency of adverse reactions was 4.6% (2.3% local and 2.2% systemic). The percentage of patients affected by systemic reaction was 18% and by local reaction 14%. No relationship can be shown between adverse reactions and gender or disease. However, a clear relationship with the composition of immunotherapy has been shown, with a lower risk of adverse reactions associated with the extract of D. pteronyssinus. The shorter period required to achieve the maintenance dose, with a similar frequency of adverse events, leads to the conclusion that the proposed administration regimen can be an alternative to conventional schedule to increase patient compliance.

Coronary artery disease diagnosis based on exercise electrocardiogram indexes from repolarisation, depolarisation and heart rate variability

Several indexes have been reported to improve the accuracy of exercise test electrocardiogram (ECG) analysis in the diagnosis of coronary artery disease (CAD), compared with the classical ST depression criterion. Some of them combine repolarisation measurements with heart rate (HR) information (such as the so-called ST/HR hysteresis); others are obtained from the depolarisation period (such as the Athens QRS score); finally, there are heart rate variability (HRV) indexes that account for the nervous system activity. The aim of this study was to identify the best exercise ECG indexes for CAD diagnosis. First, a method to automatically estimate repolarisation and depolarisation indexes in the presence of noise during a stress test was developed. The method is divided into three stages: first, a preprocessing step, where QRS detection, filtering and baseline beat rejection are applied to the raw ECG, prior to a weighted averaging; secondly, a post-processing step in which potentially noisy averaged beats are identified and discarded based on their noise variance; finally, the measurement step, in which ECG indexes are computed from the averaged beats. Then, a multivariate discriminant analysis was applied to classify patients referred for the exercise test into two groups: ischaemic (positive coronary angiography) and low-risk (Framingham risk index < 5%). HR-corrected repolarisation indexes improved the sensitivity (SE) and specificity (SP) of the classical exercise test (SE = 90%, SP = 79% against SE = 65%, SP = 66%). Depolarisation indexes also achieved an improvement over ST depression measurements (SE = 78%, SP = 81%). HRV indexes obtained the best classification results in our study population (SE = 94%, SP = 92%) by means of the very high-frequency power (VHF) (0.4-1 Hz) at stress peak.

Location of zinc and 65Zn in spinal ganglia of the rat

Following the works of Velazquez et al. (1999), Jo-Seung et al. (2000), Wang et al. (2001), Danscher et al. (2001) and the criteria of Zinc-containing neurons established by Frederickson et al.(2000), we have found the presence and localisation of Zinc in the neurons of the dorsal root ganglia of Wistar rat, by using Timm's thecnique and by studying the autoradiographic uptake of 65Zn. The agreement between the results of both techniques allows us to classify these spinal ganglion neurons as Zinc-containing neurons and also, to confirm some of the results of Velazquez et al. (1999).

65Zn uptake in the rat cerebellum and brainstem

We have studied the autoradiographic uptake of 65Zn in the cerebellum and brainstem of the rat, contrasting these results with Timm's positivity in these structures. Both, autoradiographic uptake and histochemical positivity, have demonstrated Zinc in a location that could be accepted as in climbing fibres and glomeruli of the cerebellum cortex, and also in brainstem neurons that project their axons to the cerebellum cortex, suggesting a circuit where zinc may act as a neuromodulator.

Is prosthetic umbilical hernia repair bound to replace primary herniorrhaphy in the adult patient?

Given the outstanding outcome that prosthetic repair has recently achieved in the repair of inguinal hernia, we wonder whether it should be implemented as the gold-standard technique for umbilical hernia repair. We report on 213 adult patients who underwent surgery for umbilical hernia at our Day Surgery Unit from June 1992 to January 1998. Criteria for exclusion included problematic social and family environment and ASA IV status. A polypropylene plug was placed in small umbilical defects, whereas large defects (> 3 cm in diameter) were repaired with a polypropylene mesh. The mean follow-up was 64 months. The mean age was 57.1 years, with females accounting for the majority (57.8%). Most patients (88.3%) were classified as ASA I-II. With regard to the hernia size, 143 patients (67.1%) presented with small defects (< 3 cm). The anaesthetic technique of choice was local plus sedation. Reported complications included seroma (5.6%), haematoma (2.3%), wound infection (1.4%), and intolerance to prosthesis (0.95%), the last causing recurrence. The overall recurrence rate at a mean follow-up of 64 months was 0.95%. Prosthetic umbilical hernia repair can safely be performed in adults, and the rate of recurrence in this study is low in comparison to primary tissue repair.

Risk of upper gastrointestinal bleeding in patients taking low-dose aspirin for the prevention of cardiovascular diseases

BACKGROUND

Most patients with vascular-occlusive diseases benefit from low-dose aspirin (75-325 mg/day). However, they have an increased risk of upper gastrointestinal bleeding (UGIB).

AIMS

To analyse the incidence and factors influencing the occurrence of UGIB in patients taking low-dose aspirin for the prevention of cardiovascular diseases outside clinical trials.

METHODS

We studied 903 consecutive patients discharged on low-dose aspirin from the Cardiology Department of a general hospital. Data were collected from medical charts and structured telephone interviews.

RESULTS

Forty-one patients (4.5%) presented with UGIB requiring hospitalization during follow-up (45 +/- 22 months). The incidence of UGIB was uniform during follow-up (1.2 UGIB per 100 patient years). Multivariate analysis showed that a history of peptic ulcer or UGIB [risk ratio: 3.1, 95% CI: (1.5-6.5)] and aspirin dose (per 100 mg/day) [1.8 (1.5-2.9)] was associated with higher risk of UGIB. On the other hand, antisecretory [0.22 (0.07-0.75)] and nitrovasodilator drugs [0.73 (0.55-0.96)] were associated with a decreased risk.

CONCLUSIONS

Cardiovascular patients on long-term low-dose aspirin have a stable risk of major UGIB, which is higher than published controlled clinical trials. Antisecretory and nitrovasodilator drugs protect from UGIB, whereas previous peptic ulcer or UGIB and higher doses of aspirin increase the risk.

Helicobacter pylori increases the risk of upper gastrointestinal bleeding in patients taking low-dose aspirin

AIM

To evaluate the role of Helicobacter pylori infection and other clinical factors in the risk of upper gastrointestinal bleeding in patients taking low-dose aspirin.

SUBJECTS AND METHODS

A case-control study was carried out of consecutive current users of low-dose aspirin admitted because of upper gastrointestinal bleeding. Within a cohort of 695 patients with upper gastrointestinal bleeding, 98 patients had taken low-dose aspirin and no other non-steroidal anti-inflammatory drug. Controls were 147 low-dose aspirin users without upper gastrointestinal bleeding of similar age, sex and extent of aspirin use as cases. H. pylori infection was determined by CagA/VacA serology and 13C-urea breath test in all cases and controls. Adjusted odds ratios (OR) are provided.

RESULTS

H. pylori infection was identified as an independent risk factor of upper gastrointestinal bleeding in this population (OR, 4.7; 95% confidence interval (95% CI), 2.0-10.9), but the presence of CagA-positive serology was not. Other risk factors identified were a previous ulcer history (OR, 15.2; 95% CI, 3.8-60.1), alcohol use (OR, 4.2; 95% CI, 1.7-10.4) and use of calcium channel blockers (OR, 2.54; 95% CI, 1.25-5.14). Antisecretory therapy (OR, 0.1; 95% CI, 0.02-0.3) and nitrovasodilators (OR, 0.2; 95% CI, 0.1-0.6) decreased the risk of bleeding.

CONCLUSIONS

H. pylori infection is a risk factor for upper gastrointestinal bleeding in low-dose aspirin users, which might have therapeutic implications in high-risk patients.