Prophylactic gastrostomy tubes for patients receiving radical radiotherapy for head and neck cancers: a retrospective review

Patients undergoing radical radiotherapy for head and neck cancers often experience significant complications. We sought to evaluate the impact of prophylactic gastrostomy tubes (PGTs) among these patients on four easily evaluable adverse outcomes, namely, absolute weight loss, percentage weight loss, admissions for nutritional reasons and treatment interruptions. A retrospective review was carried out on patients undergoing radical radiotherapy for primary head and neck cancers from September 1999 to October 2005 at the Wellington Blood and Cancer Centre (n = 71). PGTs were placed in 7 (10%) patients. Patients with PGTs were compared with the patients without PGTs (the control group) by univariate and multivariate analyses. By univariate analysis, there was no significant difference in absolute or percentage weight loss between those with PGTs and the control group. By multivariate analysis, those with PGTs lost 5.2% (P = 0.016) less weight than the control group. There were no significant differences between the two groups with regard to admissions for nutritional reasons or treatment interruptions. The use of PGTs can reduce weight loss in patients undergoing radical radiotherapy for head and neck cancers, and its use should be further evaluated in future studies.

A radiologic score to distinguish autoimmune hypophysitis from nonsecreting pituitary adenoma preoperatively

BACKGROUND AND PURPOSE

Autoimmune hypophysitis (AH) mimics the more common nonsecreting pituitary adenomas and can be diagnosed with certainty only histologically. Approximately 40% of patients with AH are still misdiagnosed as having pituitary macroadenoma and undergo unnecessary surgery. MR imaging is currently the best noninvasive diagnostic tool to differentiate AH from nonsecreting adenomas, though no single radiologic sign is diagnostically accurate. The purpose of this study was to develop a scoring system that summarizes numerous MR imaging signs to increase the probability of diagnosing AH before surgery.

MATERIALS AND METHODS

This was a case-control study of 402 patients, which compared the presurgical pituitary MR imaging features of patients with nonsecreting pituitary adenoma and controls with AH. MR images were compared on the basis of 16 morphologic features besides sex, age, and relation to pregnancy.

RESULTS

Only 2 of the 19 proposed features tested lacked prognostic value. When the other 17 predictors were analyzed jointly in a multiple logistic regression model, 8 (relation to pregnancy, pituitary mass volume and symmetry, signal intensity and signal intensity homogeneity after gadolinium administration, posterior pituitary bright spot presence, stalk size, and mucosal swelling) remained significant predictors of a correct classification. The diagnostic score had a global performance of 0.9917 and correctly classified 97% of the patients, with a sensitivity of 92%, a specificity of 99%, a positive predictive value of 97%, and a negative predictive value of 97% for the diagnosis of AH.

CONCLUSIONS

This new radiologic score could be integrated into the management of patients with AH, who derive greater benefit from medical as opposed to surgical treatment.

Frontal sinus osteoma complicated by extended intracranial mucocele and cerebral abscess: neurosurgical strategy of a rare clinical entity

The combination of paranasal sinus osteoma, mucocele and brain abscess is rare. Only one other case has been reported so far, where the cerebral abscess was diagnosed intraoperatively. We report here on a second patient with combined frontal sinus osteoma, intracerebral mucocele as well as cerebral abscess. However, in our case, the diagnosis of cerebral abscess was reached prior to surgery, which allowed for a tailored treatment strategy with abscess puncture under neuronavigational guidance and, after 3 weeks of antibiotic therapy with documented abscess shrinkage, osteoma and mucocele resection as well as reconstruction of the eroded dura.

Atrial natriuretic peptide during exercise in patients with coronary heart disease before and after single dose atenolol and acebutolol

Plasma atrial natriuretic peptide (ANP) was measured during dynamic exercise in 10 patients with coronary heart disease before and after single dose atenolol 50 mg and acebutolol 200 mg, respectively. Systolic blood pressure, heart rate and the rate-pressure product increased during exercise before and after beta-blockade, but levels were lower after beta-blockade. Plasma ANP levels at rest were unchanged after atenolol, but rose after acebutolol (p less than 0.01). During exercise plasma ANP increased significantly both before and after beta-blockade, but plasma ANP levels were higher after acebutolol at all workloads (p less than 0.05), whereas plasma ANP levels after atenolol were higher at 125 W exclusively (p less than 0.05). The augmented ANP levels during exercise after beta-blockade probably reflect catecholamine-stimulated ANP release, whereas the elevated plasma ANP levels after acebutolol at rest might be a beta-adrenoceptor-mediated ANP release due to the intrinsic sympathomimetic effect of acebutolol.

Correction of respiratory acidosis and transient hypomagnesemia

Four elderly patients with established chronic obstructive airways disease were admitted with a days' to weeks' history of increasing dyspnea. Acute respiratory acidosis was diagnosed and mechanical ventilation instituted. A few hours after initiation of treatment, arterial pH was normal in all patients, but serum magnesium concentrations decreased over the next 1-3 days. Thereafter, a spontaneous normalization was seen. It is suggested that the transient hypomagnesemia is due to correction of the acidosis per se.

Changes in plasma atrial natriuretic peptide during exercise in healthy volunteers

Graded exercise was performed in three healthy volunteers. Plasma levels of immunoreactive atrial natriuretic peptide (iANP) were determined at different workloads. Unchanged or slightly decreased plasma levels of iANP were observed during light exercise, whereas at medium to high workloads a considerable increase in plasma levels of iANP was found. Factors responsible for the increase in plasma levels of iANP might include elevated right atrial pressure and increased plasma levels of epinephrine and norepinephrine.

Flow cytometric analysis of RNA synthesis by detection of bromouridine incorporation

RNA synthesis has traditionally been investigated by a laborious and time-consuming radiographic method involving incorporation of tritiated uridine. Now a faster non-radioactive alternative has emerged, based on immunocytochemical detection. This method utilizes the brominated RNA precursor bromouridine, which is taken into a cell, phosphorylated, and incorporated into nascent RNA. The BrU-substituted RNA is detected by permeabilizing the cells and staining with certain anti-BrdU antibodies. This dynamic approach yields information complementing that provided by cellular RNA content analysis at a given time and may be of value in studies of cellular activation and gene expression.

Gene expression analysis of interferon-beta treatment in multiple sclerosis

Treatment with interferon-beta (IFN-beta) induces the expression of hundreds of genes in blood mononuclear cells, and the expression of several genes has been proposed as a marker of the effect of treatment with IFN-beta. However, to date no molecules have been identified that are stably induced by treatment with IFN-beta. We use DNA microarrays to study gene expression in 10 multiple sclerosis (MS) patients who began de novo treatment with IFN-beta. After the first injection of IFN-beta, the expression of 74 out of 3428 genes changed at least two-fold and statistically significantly (after Bonferroni correction). In contrast, we observed no persisting effects of IFN-beta on gene expression. Among the most strongly induced genes was MXA, which has been used in previous biomarker studies in MS. In addition, the study identified the induction of LGALS9 and TCIR1G, involved in negative regulation of T helper type I immunity and T-cell activation, as novel effects of IFN-beta therapy in MS.

Long-term efficacy and safety of insulin detemir compared to Neutral Protamine Hagedorn insulin in patients with Type 1 diabetes using a treat-to-target basal-bolus regimen with insulin aspart at meals: a 2-year, randomized, controlled trial

AIMS

This 24-month, multi-national, open-label, parallel group trial investigated the long-term efficacy and safety of insulin detemir and Neutral Protamine Hagedorn insulin in combination with mealtime insulin aspart in patients with Type 1 diabetes using a treat-to-target concept.

METHODS

Patients were randomized 2 : 1 to detemir (n = 331) or NPH (n = 166) groups. Basal insulin was initiated once daily (evening) and titrated individually based on self-measured plasma glucose (PG) levels, aiming for pre-breakfast and pre-dinner targets < or = 6.0 mmol/l. A second basal morning dose could be added according to pre-defined criteria.

RESULTS

After 24 months, superiority of glycated haemoglobin (HbA(1c)) was achieved with detemir compared to NPH (detemir 7.36%, NPH 7.58%, mean difference -0.22% points) [95% confidence interval (CI) -0.41 to -0.03%], with reductions of 0.94% and 0.72% points, respectively. Fasting PG (FPG(lab)) was also lower with detemir (detemir 8.35 mmol/l, NPH 9.43 mmol/l; P = 0.019). Twenty-two per cent of patients treated with detemir reached an HbA(1c) < or = 7.0% in the absence of confirmed hypoglycaemia during the last month of treatment vs. 13% on NPH (P = 0.019). Risk of major and nocturnal hypoglycaemia was 69% and 46% lower with detemir than with NPH (P < 0.001), respectively; patients treated with detemir gained less weight (detemir 1.7 kg, NPH 2.7 kg; P = 0.024). The overall safety profile was similar in the two groups and treatment with detemir did not result in any unexpected findings.

CONCLUSIONS

Long-term treatment with the insulin analogues detemir + aspart was superior to NPH + aspart in reducing HbA(1c), with added benefits of less major and nocturnal hypoglycaemia and less weight gain.

A randomised, 52-week, treat-to-target trial comparing insulin detemir with insulin glargine when administered as add-on to glucose-lowering drugs in insulin-naive people with type 2 diabetes

AIMS/HYPOTHESIS

This 52-week multinational, randomised, open-label, parallel-group, non-inferiority trial compared clinical outcomes following supplementation of oral glucose-lowering drugs with basal insulin analogues detemir and glargine in type 2 diabetic patients.

METHODS

Insulin-naive adults (n=582, HbA(1c) 7.5-10.0%, BMI <or= 40.0 kg/m(2)) were randomised 1:1 to receive insulin detemir or glargine once daily (evening) actively titrated to target fasting plasma glucose (FPG) <or= 6.0 mmol/l. An additional morning insulin detemir dose was permitted if pre-dinner plasma glucose (PG) was >7.0 mmol/l after achieving FPG <7.0 mmol/l. Due to labelling restrictions, no second glargine dose was allowed.

RESULTS

Baseline HbA(1c) decreased from 8.6 to 7.2 and 7.1% (NS) with detemir and glargine, respectively. FPG improved from 10.8 to 7.1 and 7.0 mmol/l (NS), respectively. With detemir, 45% of participants completed the study on once daily dosing and 55% on twice daily dosing, with no difference in HbA(1c). Overall, 52% of participants achieved HbA(1c) <or= 7.0%: 33% (detemir) and 35% (glargine) without hypoglycaemia. Within-participant variability for self-monitored FPG and pre-dinner PG did not differ by insulin treatment, nor did the relative risk of overall or nocturnal hypoglycaemia. Modest reductions in weight gain were seen with detemir vs glargine in completers (3.0 vs 3.9 kg, p=0.01) and in the intention-to-treat population (2.7 vs 3.5 kg, p=0.03), primarily related to completers on once-daily detemir. Mean daily detemir dose was higher (0.78 U/kg [0.52 with once daily dosing, 1.00 U/kg with twice daily dosing]) than glargine (0.44 IU/kg). Injection site reactions were more frequent with detemir (4.5 vs 1.4%).

CONCLUSIONS/INTERPRETATION

Supplementation of oral agents with detemir or glargine achieves clinically important improvements in glycaemic control with low risk of hypoglycaemia. Non-inferiority was demonstrated for detemir using higher insulin doses (mainly patients on twice daily dosing); weight gain was somewhat reduced with once daily insulin detemir.

Influence of mineral and organic fertilization on soil fungi, enzyme activities and humic substances in a long-term field experiment

Changes in microfungal communities, fungal activities and humic substances (HS) in agricultural soils kept under different fertilization regimes were observed and their causal relationships were investigated in a long-term field experiment. Fertilization did not change the abundance of HS-utilizing microfungi and, except for organic amendment alone, total culturable microfungi were also unaffected by this factor. Organic fertilization increased activities of manganese peroxidase (MnP) and proteinase, but decreased endo-1,4-beta-glucanase activity compared to the corresponding control without organic fertilization. In soils treated with mineral fertilizers, the activities of MnP, endo-1,4-beta-glucanase and proteinase were higher than in control without any mineral treatment. Both the aromaticity of fulvic acid and the molar mass of humic acid was lower in soil with organic fertilization, which may be a result of oxidative degradation mediated by higher MnP activity observed in treatments with organic fertilization.

Preprocedural C-reactive protein levels predict stroke and death in patients undergoing carotid stenting

BACKGROUND AND PURPOSE

Elevated baseline levels of C-reactive protein (CRP) are associated with an adverse outcome during coronary stent placement. The aim of this study was to evaluate whether preprocedural CRP levels also are predictive of stroke and death in patients undergoing carotid stent placement (CAS).

MATERIALS AND METHODS

We reviewed data prospectively collected from 130 patients (97 men, 33 women; mean age, 68.5 +/- 10.1 years; range, 43-89 years) who underwent CAS for symptomatic carotid stenosis and from whom preprocedural CRP values had been obtained. A CRP value of >5 mg/L was considered to be elevated. The frequency of stroke and death within 30 days was compared between patients with and without elevated baseline CRP levels using chi(2) and multivariate logistic regression analysis.

RESULTS

Baseline CRP values were normal in 94 (72.3%) patients but were elevated in 36 (27.7%) patients. The demographic and clinical characteristics were similar in both treatment groups. The 30-day stroke and death rate was significantly higher in patients with elevated CRP values (8/36; 22.2%) than in those without (3/94; 3.2%; P < .01). After adjusting for demographic characteristics, degree of carotid stenosis, and use of cerebral protection devices and/or statin therapy, an elevated CRP value before CAS remained a significant and independent predictor of stroke and death within 30 days after CAS (odds ratio, 7.7; 95% confidence interval: 1.8-32.8, P = .006).

CONCLUSIONS

Baseline CRP is a powerful predictor of outcome in patients undergoing CAS, which underscores the role of inflammation in the pathogenesis of embolic complications during this procedure.

Organic and mineral fertilization, respectively, increase and decrease the development of external mycelium of arbuscular mycorrhizal fungi in a long-term field experiment

Effects of long-term mineral fertilization and manuring on the biomass of arbuscular mycorrhizal fungi (AMF) were studied in a field experiment. Mineral fertilization reduced the growth of AMF, as estimated using both measurements of hyphal length and the signature fatty acid 16:1omega5, whereas manuring alone increased the growth of AMF. The results of AMF root colonization followed the same pattern as AMF hyphal length in soil samples, but not AMF spore densities, which increased with increasing mineral and organic fertilization. AMF spore counts and concentration of 16:1omega5 in soil did not correlate positively, suggesting that a significant portion of spores found in soil samples was dead. AMF hyphal length was not correlated with whole cell fatty acid (WCFA) 18:2omega6,9 levels, a biomarker of saprotrophic fungi, indicating that visual measurements of the AMF mycelium were not distorted by erroneous involvement of hyphae of saprotrophs. Our observations indicate that the measurement of WCFAs in soil is a useful research tool for providing information in the characterization of soil microflora.