Organochlorine contaminants in flounder (Platichthys flesus) and mullet (Mugil cephalus) from Douro estuary, and their use as sentinel species for environmental monitoring

In order to monitor the presence of organic pollutants in Douro estuary (NW Portugal), two sentinel fish species, grey mullet (Mugil cephalus) and flounder (Platichthys flesus), were periodically sampled from May 2001 to April 2002. At all sampling periods, several specimens of both species were allowed to depurate in clean sea water. Levels of PCBs and DDTs were quantified in liver and muscle of both species. The accumulation of PCBs was higher in muscle of mullet, with a maximum of 345 ng/g dw, than in flounder, with a maximum 52ng/g dw. In the liver, flounder showed the highest levels (811 ng/g dw). Of the 18 congeners analysed, CBs 180 (hepta), 153 and 138 (hexachlorobiphenyls) were predominant in the tissue of both species. The maximum concentration of tDDT was measured in flounder liver (301ng/g dw). In contrast, a 10-fold higher tDDT was recorded in mullet muscle (63-69 ng/g dw and 8-16 ng/g dw for mullet and flounder, respectively). The hepatic ethoxyresorufin O-deethylase (EROD) activity was periodically determined. Consistently, a 10-fold higher enzymatic activity was present in mullet in comparison with flounder (1536 pmol/min/mg protein in mullet and 156 pmol/min/mg protein in flounder). In mullet, no correlation could be found between EROD activity and gonado-somatic index (GSI) or hepato-somatic index (HSI). On the contrary, during the reproductive season, female flounder showed a negative correlation between EROD activity and GSI. Despite being in clean sea water for 1 month period, no significant decrease in the tissue content of PCBs and tDDT was found. However, mullet's EROD activity followed a clear pattern, with a decrease enzymatic activity after being in captivity. Female flounder displayed a similar trend during the resting season. Yet, during the reproductive season, an increased EROD activity was recorded after being in captivity for 1 month, which may be associated with a modulation effect of steroids on CYP 1A1. Histological analyses of gonad revealed that 21% of male mullet displayed testis-ova, while no male flounder was found to show gonadal abnormalities. Overall, the study reports the accumulation of significant levels of PCBs and DDTs in the tissues of the studied species. It also provides important evidences supporting the use of grey mullet as a sentinel species for monitoring the presence of organic contaminants and xeno-estrogenic pollution in southern European estuaries.

Dieulafoy's lesion: management and long-term outcome

BACKGROUND AND STUDY AIMS

Dieulafoy's lesion is usually considered to be a rare cause of gastrointestinal bleeding and little information is available about the long-term follow-up of this condition. We studied the clinical pattern and long-term outcome in patients with Dieulafoy's lesion who were managed in a gastrointestinal intensive care unit.

PATIENTS AND METHODS

We reviewed the data on the diagnosis, treatment, and outcome of 70 patients admitted to our unit for acute upper gastrointestinal bleeding due to Dieulafoy's lesion. Endoscopic hemostasis was performed in 69 cases. Patients underwent surgery if endoscopic therapy failed. A phone interview was carried out to assess the long-term clinical outcome.

RESULTS

Dieulafoy's lesion accounted for 4 % of cases of upper gastrointestinal bleeding in patients admitted during the period studied. The mean number +/- SD of endoscopies required to establish the diagnosis was 1.4 +/- 0.75. Endoscopic hemostasis was initially successful in 91.3 % of patients, while nearly 16 % of patients required surgery because endoscopic therapy failed. The overall mortality rate was 8.6 %. None of the 52 patients who were followed up by phone reported recurrent bleeding after discharge from hospital, in a mean follow-up period of 69 months.

CONCLUSIONS

Dieulafoy's lesion is a not uncommon cause of severe recurrent gastrointestinal bleeding. Endoscopic therapy is safe and effective in achieving permanent hemostasis. The long-term prognosis for Dieulafoy's lesion is excellent, even when patients are treated using endoscopic methods alone.

Cytoprotection by Achyrocline satureioides (Lam) D.C. and some of its main flavonoids against oxidative stress

Epidemiological studies indicate that dietary antioxidants can influence the incidence of neurodegenerative diseases. Among them flavonoids have been proposed to be effective cytoprotectors. Consequently, herbs with a high concentration of these compounds such as Achyrocline satureioides, Ginkgo biloba and Epilobium parviflorum are of special interest. In this context a comparative study of the cytoprotective capacity of infusions from the three plants against an oxidative insult was performed. Hence, the cytoprotective activity of each infusion against H2O2 injury to PC12 cells was tested and the antioxidant capacity was assessed by the ABTS*+ radical bleaching assay. Free and glycosylated flavonoids contained in the infusions were identified by HPLC and the cytoprotective effect of some of these individual flavonoids was tested. The analysis of the flavonoid content of the infusions revealed different profiles. Epilobium parviflorum infusion showed the highest antioxidant capacity but only Achyrocline satureioides infusion proved to be cytoprotective. Moreover, the free flavonoids quercetin and luteolin contained in this infusion were also cytoprotective. In conclusion, the free radical scavenger capacity did not correlate with the cytoprotective profile of the infusions. The special mixture of unglycosylated Achyrocline satureioides flavonoids could be a clue to explain the unique effect of this plant.

Neuroprotection by flavonoids

The high morbidity, high socioeconomic costs and lack of specific treatments are key factors that define the relevance of brain pathology for human health and the importance of research on neuronal protective agents. Epidemiological studies have shown beneficial effects of flavonoids on arteriosclerosis-related pathology in general and neurodegeneration in particular. Flavonoids can protect the brain by their ability to modulate intracellular signals promoting cellular survival. Quercetin and structurally related flavonoids (myricetin, fisetin, luteolin) showed a marked cytoprotective capacity in in vitro experimental conditions in models of predominantly apoptotic death such as that induced by medium concentrations (200 M) of H2O2 added to PC12 cells in culture. Nevertheless, quercetin did not protect substantia nigra neurons in vivo from an oxidative insult (6-hydroxydopamine), probably due to difficulties in crossing the blood-brain barrier. On the other hand, treatment of permanent focal ischemia with a lecithin/quercetin preparation decreased lesion volume, showing that preparations that help to cross the blood-brain barrier may be critical for the expression of the effects of flavonoids on the brain. The hypothesis is advanced that a group of quercetin-related flavonoids could become lead molecules for the development of neuroprotective compounds with multitarget anti-ischemic effects.

Pesticides in Portuguese surface and ground waters

Pesticides used in Portuguese agricultural areas have been found in surface and ground waters. In the surface water collected in three river basins from 1983 to 1999, insecticides and herbicides were detected from the monitored pesticides, particularly atrazine, chlorfenvinphos (Z+E), alpha- and beta-endosulfan, lindane, molinate and simazine, reaching the maximum values, respectively, of 0.63, 31.6, 0.18 microg/L (alpha-endosulfan), 0.18 microg/L (beta-endosulfan), 0.24, 48 and 0.3 microg/L. In the ground water collected from the wells of seven agricultural areas from 1991 to 1998, several monitored herbicides were detected: alachlor, atrazine, metolachlor, metribuzine and simazine, reaching the maximum concentration values of 13, 30, 56, 1.4 and 0.4 microg/L, respectively. The herbicides more frequently detected were atrazine (64%), simazine (45%) and alachlor (25%). Other than these, the monitored pesticides can be present in Portuguese surface and ground waters. Therefore, to improve the analytical conditions, the use of multiresidue methods and automated techniques are desirable in future work.

Screening of antioxidant activity of three Indian medicinal plants, traditionally used for the management of neurodegenerative diseases

A number of Indian medicinal plants have been used for thousands of years in the traditional system of medicine (Ayurveda). Amongst these are plants used for the management of neurodegenerative diseases such as Parkinson's, Alzheimer's, loss of memory, degeneration of nerves and other neuronal disorders by the Ayurvedic practitioners. Though the etiology of neurodegenerative diseases remains enigmatic, there is evidence, which indicates that defective energy metabolism, excitotoxicity and oxidative damage may be crucial factors (Ann. Neurol. 38 (3) (1995) 357). The part of the Ayurvedic system that provides an approach to prevention and treatment of degenerative diseases is known as Rasayana, and plants used for this purpose are classed as rejuvenators. This group of plants generally possesses strong antioxidant activity (Pharmacol. Biochem. Behav. 43 (1992) 1175), but only a few have been investigated in detail. In the present study, three such rasayana plants were tested for the first time for their toxicity and free radical scavenging activity both in vitro and ex vivo. All the three plant infusions (up to 1 mg/ml) showed no toxic effects on the viability of PC12 cell line as judged by MTT-test. Both ethanolic extracts and water infusions of the plants were tested for their antioxidant activity in the 2,2'-azinobis-3-ethyl-benzothiazoline-6-sulfonic acid (ABTS*(+)) radical cation decolorization assay; inhibition of lipid peroxidation by plant infusions was carried out using spontaneous lipid peroxidation of rat brain homogenate, and IC50 values were determined. The results from the ABTS assay showed that the ethanolic extract of Sida cordifolia was found to be most potent (IC50 16.07 microg/ml), followed by Evolvulus alsinoides (IC50 33.39 microg/ml) and Cynodon dactylon (IC50 78.62 microg/ml). The relative antioxidant capacity for the water infusions was observed in the following order: E. alsinoides (IC50 172.25 microg/ml)>C. dactylon (IC50 273.64 microg/ml)>S. cordifolia (IC50 342.82 microg/ml). The results of water infusions of the plants on lipid peroxidation were as follows: E. alsinoides (IC50 89.23 microg/ml)>S. cordifolia) (IC50 126.78 microg/ml)>C. dactylon (IC50 608.31 microg/ml).

[Constrictive pericarditis: an early diagnosis?]

The authors report a case study of a 73-year-old male, with signs of right-sided heart failure with 6 months of evolution. It was constrictive pericarditis, without radiologic, echocardiographic and magnetic resonance imaging manifestations, diagnosed on the basis of the clinical situation and hemodynamic evaluation during cardiac catheterization. The authors suggest that the lack of imagiologic manifestations might have been the result of an early diagnosis, before the development of the classic picture. Pericardiectomy, performed with success, was followed by resolution of the heart failure. It was not possible, histologically, to draw conclusions about the etiology. The development of mitral regurgitation after pericardiectomy has enriched this case with an unusual, but previously described, complication of this type of surgery.

Axotomy and nerve growth factor regulate levels of neuronal nicotinic acetylcholine receptor alpha3 subunit protein in the rat superior cervical ganglion

Neuronal nicotinic acetylcholine receptors (nAChRs) play a significant role in sympathetic transmission in the superior cervical ganglia (SCG), with most of the signal carried by a nAChR containing an alpha3 subunit. Work has shown that transection of the postganglionic nerves (axotomy) of the SCG results in a decrease in mRNA transcripts for alpha3, alpha5, alpha7 and beta4 and in protein expression of alpha7 and beta4. To evaluate effects of axotomy on alpha3 protein in the SCG, quantitative immunoblotting was used to demonstrate a dramatic decrease (> 80%) in the levels of this subunit 4 days after axotomy. Similarly, immunocytochemistry showed a marked decline in the number and the intensity of stained neurons for the alpha3 subunit as well as tyrosine hydroxylase. Ganglia explanted into culture for 4 days also showed a substantial decrease in alpha3 subunit protein. This decrease was partially prevented by the addition of nerve growth factor (NGF) to the culture medium at the time of explantation. Additionally, this decrease was reversed by the addition of NGF to the culture medium following 4 days in culture in the absence of NGF. These findings suggest that the loss of alpha3 subunit contributes to the reported decrease in ganglionic synaptic transmission that follows axotomy, and that NGF plays an important role in regulating the expression of alpha3-containing nAChRs in the SCG.

Glucose effects on gastric motility and tone evoked from the rat dorsal vagal complex

1. To examine the effects of glucose on the central components of the vago-vagal reflex control of gastric function, we performed both in vivo and in vitro experiments on neurones in the medial nucleus of the tractus solitarius (mNTS) and in the dorsal motor nucleus of the vagus (DMV). 2. In the in vivo anaesthetized rat preparation, unilateral microinjection of D-glucose (10 or 50 mM (60 nl)(-1)) in mNTS produced inhibition of gastric motility and an increase in intragastric pressure. D-glucose had no effect in the DMV. 3. In the in vitro rat brainstem slice preparation, whole-cell recordings of DMV neurones showed that increasing the glucose concentration of the perfusion solution from 5 mM to 15 or 30 mM produced outward currents of 35 +/- 5 pA (n = 7) and 51 +/- 10 pA (n = 11), respectively. These were blocked by tetrodotoxin and picrotoxin, indicating that glucose was acting indirectly to cause the release of GABA. Decreasing the glucose concentration of the perfusing solution by one-half produced an inward current of 36 +/- 5 pA (n = 7). 4. Stimulation of the NTS evoked inhibitory postsynaptic currents (IPSCs) in DMV neurones. The amplitude of the evoked IPSCs was positively correlated with glucose concentration. Perfusion with the ATP-sensitive K(+) (K(ATP)) channel opener diazoxide mimicked the effect of reduced glucose, while perfusion with the K(ATP) channel blocker glibenclamide mimicked the effects of increased glucose. 5. Our data indicate that glucose had no direct excitatory effect on DMV neurones, but DMV neurones appear to be affected by an action of glucose on cell bodies of mNTS neurones via effects on an ATP-sensitive potassium channel.

A pilot investigation to subjectively measure treatment effect and side-effect profile of non-ablative skin remodeling using a 532 nm, 2 ms pulse-duration laser

BACKGROUND AND OBJECTIVE

Carbon dioxide laser skin resurfacing has become a standard treatment for wrinkles and sun-damaged skin. This ablative treatment, however, is associated with undesirable complications and long recovery times. A growing body of evidence suggests that dermal inflammation and subsequent collagen formation can be stimulated without removal of the epidermis, raising the possibility of effective non-ablative skin remodeling for mild to moderately photodamaged skin.

MATERIALS AND METHODS

This preliminary study was performed to evaluate the safety and subject satisfaction of non-ablative skin remodeling using a 532 nm, 2 ms pulse-duration, frequency-doubled Nd:YAG laser. Subjects with mild-to-deep lip wrinkles and mild-moderate acne scarring were treated one half of their lip (wrinkles) or cheek (acne scarring), leaving the other side as an untreated control. Subjects were treated at 3-6 week intervals for an average of three treatments. Subjective assessment of improvement was estimated by subject self-evaluation of the percentage improvement over baseline, and a blinded observer attempted to identify the treated side on physical examination.

RESULTS

Subjective assessment revealed an average improvement of 51.4% and 53.6% for upper lip wrinkles and facial acne scarring, respectively. Side effects were limited to transient erythema that resolved over 0.25-2 hours following treatment.

CONCLUSIONS

These results demonstrate that non-ablative treatment with the 532 nm, 2 ms pulse-duration Nd:YAG laser results in subjective improvement of rhytides and acne scarring, with a high safety profile.

Phytochemical profiles of Targionia lorbeeriana: grown in vitro and in the open

The terpenoid constituents of Targionia lorbeeriana grown in vivo and in vitro were compared. The analysis of the dichloromethane extract was performed by HPLC-UV and by HPLC-MS. The obtained results revealed that the sesquiterpene lactones isolated from the dichloromethane extract of the wild Targionia lorbeeriana were also produced by the liverwort in in vitro cultures, in the same relative amounts. The composition of essential oils was evaluated by GC and GC-MS. Both, the yield and diversity of the essential oil obtained from wild growing T. lorbeeriana gametophytes were higher than those growing in vitro. Although, a significant number of compounds produced in vivo were maintained in vitro, a considerable number of other ones were not detected. Instead, under in vitro conditions, some new compounds were found which do not accumulate under wild conditions.

Cooperativity of phospholipid reorganization upon interaction of dipyridamole with surface monolayers on water

Results from various surface sensitive characterization techniques suggest a model for the interaction of the piperidinopyrimidine dipyridamole (DIP)--known as a vasodilator and inhibitor of P-glycoprotein associated multidrug resistance of tumor cells--with phospholipid monolayers in which the drug is peripherally associated with the membrane, binding (up to) five phospholipids at a time. These multiple interactions are responsible for a very strong association of the drug with the lipid monolayer even at exceedingly low concentrations (approximately 0.2 mol%). Electrostatic interactions and hydrogen bonding are likely involved in the binding of DIP to DPPC. Cooperative effects among the lipids are invoked to explain the macroscopically measurable changes of lipid monolayer properties even when only one out of 100 DPPC molecules is directly associated with a DIP molecule. A reversal of the observed changes upon drug association with the membrane as the DIP concentration surpasses a threshold concentration (c(crit)approximately 0.5 mol%) may be explained by cooperativity in a different context, the self-aggregation of drug molecules. With its implications for the interaction of DIP with phospholipid films, this work provides a first approach to the explanation of the high sensitivity of cell membranes to piperidinopyrimidine drugs on a molecular level.

Suicide attempts and the tryptophan hydroxylase gene

Tryptophan hydroxylase (TPH) is the rate-limiting enzyme of serotonin synthesis. In this case-control study, we investigated whether the TPH gene was a susceptibility factor for suicidal behavior. Seven polymorphisms spanning the entire gene were studied in a case-control study including 231 individuals who had attempted suicide and 281 controls. Significant associations were found between variants in introns 7, 8 and 9 (chi(2) = 11.2, df = 1, P< 0.0008 for the allele distribution; these loci are in complete linkage disequilibrium) and in the 3' noncoding region (chi(2) = 30.94, P = 0.0014) and suicide attempt. The association was strongest for subjects who had attempted suicide by violent means and who had a history of major depression. No significant association was observed between suicide attempts and polymorphisms in the promoter, intron 1 and intron 3. The results presented here, and those of previous studies, suggest that a genetic variant of the 3' part of the TPH gene may be a susceptibility factor for a phenotype combining suicidal behavior, mood disorder and impulsive aggression.

Evidence of a functional alpha7-neuronal nicotinic receptor subtype located on motoneurons of the dorsal motor nucleus of the vagus

In vitro autoradiography using 125I-alpha-bungarotoxin (alpha-BGTx) and anti-alpha7 immunohistochemistry were performed on the dorsal motor nucleus of the vagus (DMV) of sham and chronically vagotomized rats to determine whether the alpha7-nicotinic acetylcholine receptor (nAChR) is located postsynaptically on DMV neurons whose axons contribute to the vagus nerve. Intense bilateral 125I-alpha-BGTx binding and anti-alpha7 immunostaining were observed in coronal brain sections containing the DMV of sham-vagotomized animals. Unilateral cervical vagotomy resulted in ipsilateral losses of 125I-alpha-BGTx binding and anti-alpha7 immunostaining from the DMV. Simultaneous staining of rat brainstem sections with anti-alpha7 and anti-choline acetyltransferase (ChAT) antibodies (to identify cholinergic DMV neurons that project into the vagus nerve) revealed that every DMV neuron that was stained for ChAT showed alpha7-staining as well. In vagotomized animals, no ChAT-positive neurons expressing alpha7-nAChRs remained in the ipsilateral DMV. We conclude that the alpha7-nAChR subtype is located postsynaptically on DMV neurons. To test whether the alpha7-nAChR is similar to the alpha7-homomeric nAChR, experiments were performed in anesthetized rats, and compounds were microinjected into the DMV while monitoring intragastric pressure (IGP). alpha-BGTx and strychnine antagonized nicotine-induced increases in IGP; no antagonism was observed with methyllycaconitine, a compound known to block the homomeric alpha7-nAChR subtype. Recovery from alpha-BGTx-induced antagonism of the nicotine response was observed. We conclude that there is a nAChR containing the alpha7-subunit in the DMV that is different from the homomeric alpha7-nAChR subtype.

Endoscopic injection therapy vs. multipolar electrocoagulation vs. laser vs. injection + octreotide vs. injection + omeprazole in the treatment of bleeding peptic ulcers. A prospective randomized study

BACKGROUND/AIMS

A prospective randomized study was performed to assess the effectiveness and safety of 5 different methods of hemostasis in selected patients with high-risk bleeding peptic ulcers.

METHODOLOGY

Two hundred and eight patients (n = 208; mean age: 61.6 yrs) with endoscopic stigmata of active hemorrhage, non-bleeding vessel or adherent fresh clot were randomized during emergency endoscopy to receive one of the following modalities of endoscopic therapy (with or without pharmacological therapy): I) injection of absolute alcohol (n = 44); II) multipolar electrocoagulation (BICAP; n = 42); III) Nd-YAG laser (n = 40); IV) injection of absolute ethanol + octreotide (n = 42); V) injection of absolute ethanol + omeprazole (n = 40).

RESULTS

The 5 treatment groups were clinically and endoscopically comparable. The initial hemostatic success was > 90% in every group. No significant differences between groups were found in any of the following parameters assessed during hospitalization: incidence of rebleeding (I = 14.8% vs. II = 19.0% vs. III = 16.6% vs. IV = 18.1% vs. V = 20.0%; P > 0.05 mean = 17.7%); incidence of definitive hemostasis (I = 89.3% vs. II = 85.7% vs. III = 86.6% vs. IV = 84.0% vs. V = 86.6%; P > 0.05; mean = 86.5%); incidence of emergency surgery (I = 8.5% vs. II = 11.9% vs. III = 10.0% vs. IV = 6.8% vs. V = 11.1%; P > 0.05; mean = 9.6%); mortality rate (I = 4.2% vs. II = 4.7% vs. III = 3.3% vs. IV = 13.6% vs. V = 4.4%; P > 0.05; mean = 6.2%). Mean age of deceased patients was significantly higher than living patients (71.2 +/- 13.4 vs. 60.9 +/- 14.4; P < 0.05). Approximately 2/3 of the fatal cases were strongly weakened by coexistent medical diseases. The duration of hospital stay was similar for all groups. The BICAP group required less units of blood transfusion (1.9 +/- 1.8 vs. I = 3.0 +/- 2.6; III = 3.5 +/- 3.6; IV = 2.8 +/- 2.3; V = 3.1 +/- 2.5; P < 0.05), perhaps due to the higher mean value of hemoglobin of these patients at hospital admission, compared to all other groups. No significant complications were reported.

CONCLUSIONS

This study provides good evidence that injection of absolute ethanol, multipolar electrocoagulation (BICAP) and Nd-YAG laser are equally safe and effective in the endoscopic therapy of acute bleeding peptic ulcers. In contrast, no additional hemostatic benefits arose from the association of pharmacological agents (octreotide or omeprazole) to sclerosis injection.

Octreotide in acute bleeding esophageal varices: a prospective randomized study

BACKGROUND/AIMS

To assess the value of octreotide in the control of acute bleeding esophageal varices, in a prospective randomized study.

METHODOLOGY

One hundred and ninety-seven patients admitted for variceal bleeding confirmed at endoscopy were recruited and divided into two groups: group I (n = 111) with endoscopic stigmata of recent bleeding; and group II (n = 86) with active bleeding at emergency endoscopy. Patients in group I were randomized to receive a continuous infusion of octreotide (n = 58) or emergency sclerotherapy (n = 53). Patients in group II were assigned to sclerotherapy (n = 42) or to sclerotherapy plus octreotide (n = 44). At the end of the period of study (48 hours), patients were submitted to sclerotherapy or band ligation until variceal obliteration was achieved.

RESULTS

In group I, octreotide was found to be as effective as sclerotherapy regarding hemostasis at 48 hours and on day 7 after the index bleeding episode. Transfusion needs were not significantly different for the two treatment modalities. In group II, the association of octreotide with sclerotherapy was significantly better than sclerotherapy alone either in controlling acute active bleeding (P < 0.001) or in achieving hemostasis at 48 hours (P < 0.01). Transfusion needs were significantly fewer in patients treated with this therapeutic association as compared to sclerotherapy alone.

CONCLUSIONS

These results suggest that octreotide infusion is effective in the treatment of variceal bleeding. In patients with recent bleeding, octreotide infusion is as effective as emergency sclerotherapy. In active variceal bleeding, it is a valuable adjuvant treatment in association with emergency sclerotherapy.

Endocardial and epicardial radiofrequency ablation in the treatment of atrial fibrillation with a new intra-operative device

OBJECTIVE

Atrial fibrillation has been a difficult problem to solve in many surgical patients, especially in those with mitral valve pathology. This study evaluates the results of endocardial and epicardial radiofrequency ablation with a new intra-operative device in the treatment of atrial fibrillation.

METHODS

We operated on 65 patients with atrial fibrillation, 58 of which had concomitant mitral surgery. Atrial fibrillation was chronic (over 1 year) in 46 patients (group A) and paroxysmal or recent onset in 12 (group B). Group C had lone atrial fibrillation (two), concomitant coronary artery disease (four) or a sarcoma (one). Bilateral pulmonary vein isolation with a new intra-operative device was performed through multiple dry lesions in all patients. Groups A and B had endocardial applications at 70 degrees C during 60 s and group C had epicardial applications at 75 degrees C. Three group C patients had epicardial applications off pump. Atrial wall biopsies were performed in nine patients from groups A and B.

RESULTS

There were no serious post-operative complications. At 1 month follow-up 54% of all patients were out of atrial fibrillation and 34% were in normal sinus rhythm with bilateral atrial contraction (Santa Crus Score 4). At 6 months follow-up, in spite of some crossover of patients among groups, similar results were obtained. The success of the procedure was 69% (Santa Crus scores 3 and 4) in mitral patients with a left atrial volume smaller than 200 cm(3). Preliminary data on the transmurality of the lesions is presented. The patients submitted to epicardial radiofrequency ablation (group C) have satisfactory results at 1 month (six out of seven were out of AF).

CONCLUSIONS

Both endocardial and epicardial RF applications are simple and quick to perform and do not pose an additional risk for most patients. Furthermore we believe that it is possible to perform bilateral epicardial radiofrequency ablation of the pulmonary veins without cardiopulmonary bypass. Further refinements of the technique are needed to assure transmurality of all lesions and better results.

Brainstem nicotinic receptor subtypes that influence intragastric and arterial blood pressures

The purpose of this study was to investigate the effect of microinjection of nicotine and nicotinic receptor antagonists into the dorsal motor nucleus of the vagus (DMV) or medial subnucleus of the tractus solitarius (mNTS) on intragastric (IGP) and arterial blood pressures (BP) in anesthetized rats. Nicotine microinjected into the DMV (10-300 pmol) produced dose-related increases in IGP (ED(50) = 89 pmol); no significant changes were noted for BP. Ipsilateral vagotomy abolished nicotine-induced increases in IGP. Nicotine microinjected into the mNTS in a dose range of 0.1 to 300 pmol produced dose-related decreases in IGP (ED(50) = 0.6 pmol) and BP (ED(50) = 5.4 pmol). Bilateral vagotomy abolished nicotine-induced decreases in IGP while having no effect on BP. In rats treated with daily s.c. injections of nicotine (0.8 mg/kg of base) for 10 days, microinjections of nicotine into the DMV produced similar increases in IGP. BP responses from the mNTS were not affected by chronic treatment. However, nicotine microinjections into the mNTS no longer produced a decrease in IGP in these chronically treated animals. alpha-Bungarotoxin (100 pmol) significantly blocked nicotine-evoked increases in IGP from the DMV while having no effect on nicotine-induced responses elicited from the mNTS. Hexamethonium (10 and 100 pmol) microinjected into the mNTS dose-dependently blocked nicotine-induced effects but did not interfere with the action of nicotine at the DMV. Our data indicate that nicotine-induced changes in IGP result from nicotine acting at two sites, the DMV and mNTS; and that at least three different nicotinic receptors in the dorsal medulla oblongata can influence gastrointestinal and cardiovascular function.

Construction of a branched chain at C-3 of a hexopyranoside. Synthesis of miharamycin sugar moiety analogs

Synthesis of the conveniently protected epimer at C-3' of the miharamycin sugar moiety was accomplished starting from the corresponding 3,3'-spiroepoxide. Reaction of the epoxide with lithium cyanide, followed by hydrolysis and spontaneous cyclization, afforded the intermediate deoxylactone methyl 4,6-O-benzylidene-3-C-(carboxymethyl)-alpha-D-glucopyranoside-3',2-lacto ne (8). Stereoselective hydroxylation with MoO5 x py x HMPA, reduction with lithium aluminum hydride and cyclization with diethyl azodicarboxylate-triphenylphosphine gave the target molecule methyl 2,3''-anhydro-4,6-O-benzylidene-3-C-[(R)-1,2-dihydroxyethyl]-alpha -D-glucopyranoside (5). Direct reduction of 8 gave other analogs having no C-3' hydroxyl group together with having a C-3'' hydroxyl group (hemiacetal). In addition, C-3' epimers were also synthesized through C-3', C-3'' dihydroxy analogs. Wittig reaction of an appropriate ketosugar with [(ethoxycarbonyl)methylene]triphenylphosphorane leading to a 7:3 Z/E mixture, followed by hydroxylation with osmium tetroxide, reduction and cyclization afforded the target molecule 5 and the miharamycin sugar moiety methyl 2,3''-anhydro-4,6-O-benzylidene-3-C-[(S)-1,2-dihydroxyethyl]-alpha -D-glucopyranoside. Examination of X-ray data for 5 and its NMR spectroscopy data allowed us to explain a contradiction reported in the literature.

Evidence for an involvement of vitellogenin in the steroidogenic activity of rainbow trout (Oncorhynchus mykiss) vitellogenic oocytes

In vivo and in vitro the concentration of vitellogenin (VTG) inside the oocyte can alter VTG production by the liver, modulating the synthesis of 17beta-estradiol (E(2)) by the ovary. To gain a greater insight into this mechanism, the in vitro production of free and conjugated testosterone (T), E(2), and androstenedione (A) by rainbow trout oocytes from the early and middle vitellogenic stage was measured by radioimmunoassay. There was a decreased E(2) production that was greater in September (40%) than October (30%), by the oocytes incubated with the vitellogenic fraction. The production of E(2) conjugated as glucuronide was lower than sulfate (P < 0.05), but similar in control and VTG-incubated oocytes. Levels of free T increased from September to October, and conjugates were both produced at low levels, and no differences were detected between control and incubated VTG oocytes. The decreased synthesis of E(2) by oocytes incubated with VTG was not followed by an increase in the amount of T or conjugated E(2), because there were no differences under the two circumstances. However, there was a reduced synthesis of A with oocytes producing low levels of E(2). These results suggest that the presence of high levels of VTG in the oocyte suppresses the synthesis of A and E(2), affecting the activities of the enzymes C17,20 lyase and aromatase and probably interfering with the heme protein cytochrome P450 which in the ovary catalyses C 17,20 lyase (P450 c17) and aromatase (P450 arom).

Reversal of morphine-induced apnea in the anesthetized rat by drugs that activate 5-hydroxytryptamine(1A) receptors

The purpose of our study was to test the hypothesis that 5-hydroxytryptamine (5-HT)(1A) receptor agonists counteract morphine-induced respiratory depression. Studies were conducted in anesthetized rats, and respiratory activity was monitored with diaphragm electromyography. Morphine was administered i.v. in doses that produce apnea. Once apnea was established, i.v. administration of the 5-HT(1A) receptor agonist drug 8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT) at 10 or 100 microgram/kg restored normal breathing in each animal (n = 24). This antagonistic effect of 8-OH-DPAT on morphine-induced respiratory depression was observed in both spontaneously breathing and artificially ventilated animals. Results obtained with 8-OH-DPAT were mimicked by buspirone (50 microgram/kg i.v.), another 5-HT(1A) receptor agonist drug. Pretreatment with 4-(2'-methoxyphenyl)-1-[2'[N-(2'-pyridinyl]-p-iodo-benzamido]ethyl]pi perazine, an antagonist of 5-HT(1A) receptors, prevented 8-OH-DPAT from counteracting morphine-induced apnea. These results indicate that activation of central nervous system 5-HT(1A) receptors is an effective way of reversing morphine-induced respiratory depression. Most important, this is the third model of disturbed respiratory function in which drugs that stimulate 5-HT(1A) receptors have been shown to restore breathing to near-normal levels.

Selective determination of chromium (VI) in powdered milk infant formulas by electrothermal atomization atomic absorption spectrometry after ion exchange

A previously developed method was adapted to the selective determination of hexavalent chromium in powdered milk infant formulas. The species in reconstituted milk was separated on an ion-exchange column, Chromabond NH2, and measured by electrothermal atomization atomic absorption spectrometry. The detection limit was 1.8 micrograms/L, and the linearity range under optimized conditions was 1.8-50.0 micrograms/L. The precision values were 4.1 and 6.5% for the analytical and overall procedures, respectively. The procedure was validated by the method of standard additions (5.0, 10.0, and 25.0 micrograms/L), and the recoveries were all > 93%. The developed method is sensitive, accurate, and precise for determination of Cr(VI) in powdered milks. It was applied to the determination of Cr(VI) in 20 commercial brands, i.e., 7 infant formulas, 5 follow-up milks, and 8 dietetic milks. The values found ranged from < 10 to 75 ng/g.

Relocation of the iliac artery bifurcation to facilitate endoluminal treatment of abdominal aortic aneurysms

PURPOSE

To report a surgical technique to preserve the internal iliac arteries (IIAs) and facilitate endovascular repair of abdominal aortic aneurysms (AAAs) with extensive iliac artery involvement.

TECHNIQUE

A new iliac artery bifurcation is created surgically through an 8-cm lower left abdominal incision by implanting the IIA onto the distal external iliac artery either directly or by using a tube graft interposition. Careful technique is required to avoid embolic complications, but after relocating the bifurcation, aortic endografting can be performed, either simultaneously or staged, depending upon patient characteristics.

CONCLUSIONS

Relocation of the iliac artery bifurcation appears to be a good alternative to preserve pelvic arterial flow in selected candidates for endoluminal AAA repair.

Effects of calcium beta-hydroxy-beta-methylbutyrate (HMB) supplementation during resistance-training on markers of catabolism, body composition and strength

Calcium beta-hydroxy-beta-methylbutyrate (HMB) supplementation has been reported to reduce muscle catabolism and promote gains in fat-free mass and strength in subjects initiating training. However, whether HMB supplementation promotes these adaptations in trained athletes is less clear. This study examined the effects of HMB (as the calcium salt) supplementation during resistance training (6.9+/-0.7 hr x wk(-1)) on markers of catabolism, body composition and strength in experienced resistance-trained males. In a double-blind and randomized manner, 40 experienced resistance-trained athletes were matched and assigned to supplement their diet for 28 d with a fortified carbohydrate/protein powder containing either 0, 3 or 6 g x d(-1) of calcium HMB. Fasting venous blood and urine samples, dual energy X-ray absorptiometer-determined body composition, and isotonic bench press and leg press one repetition maximums (1 RM) were determined prior to and following 28 d of supplementation. HMB supplementation resulted in significant increases in serum and urinary HMB concentrations. However, no statistically significant differences were observed in general markers of whole body anabolic/catabolic status, muscle and liver enzyme efflux, fat/bone-free mass, fat mass, percent body fat, or 1 RM strength. Results indicate that 28 d of HMB supplementation (3 to 6 g x d(-1)) during resistance-training does not reduce catabolism or affect training-induced changes in body composition and strength in experienced resistance-trained males.

[The metabolic-chronotropic relation in patients with heart failure--a correlation with functional capacity]

Previous studies on chronotropic incompetence (CI) in patients with congestive heart failure (CHF) have defined it as the inability to achieve > 80% of age predicted maximum heart rate (HR) (adequacy of HR response to submaximal exercise levels not being considered). The metabolic chronotropic relation (MCR) concept proposed by Wilkoff allows the assessment of the entire chronotropic function. The value of such an approach for the evaluation of CI in patients with CHF, and its relation to exercise capacity, is unclear at present.

METHODS

We imposed maximal symptom-limited treadmill exercise testing while measuring breath-by-breath oxygen consumption, using CAEP protocol, in 25 patients (19 men), 49 +/- 10 years, all in sinus rhythm, with CHF secondary to dilated cardiomyopathy (17) or ischemic heart disease (8), NYHA class II-III. Anaerobic threshold (AT) was attained by all. No exercise was terminated due to arrhythmia or ischemia. MCR was calculated as the slope of the relation between the percentages of HR and metabolic reserves achieved at the end of each exercise stage. Using 2.0 standard deviations below the mean level of MCR in healthy controls, we defined an MCR value < 0.84 as abnormal. The parameters analysed were: age, drug therapy, fractional shortening (FS-%), resting HR (RHR-bpm), exercise duration (DUR-min), peak HR (HRp), peak oxygen consumption (VO2p-ml/kg/min), percentages of predicted maximal HR (% PMHR) and VO2 (% PMVO2), peak ventilatory equivalent for CO2 (VE/VCO2-L/min), time to AT (T-AT), and VO2 at AT (VO2-AT).

RESULTS

MCR was normal (1.01 +/- 0.18-0.86 to 1.19) in 10 patients--Group I, and abnormal (0.66 +/- 0.13-0.42 to 0.81) in 15 (60%) patients--Group II. A similar proportion of patients in both groups were taking ACE inhibitors, digoxin and amiodarone. [table: see text] CI defined as an inability to achieve a % PMHR > 80% occurred only in 6 (24%) patients, all in Group 2 (p = 0.022 versus abnormal MCR).

CONCLUSIONS

In CHF patients, CI assessed as an abnormal MCR is frequent, and relates to an impaired exercise capacity.

Electrosurgical treatment of atrial fibrillation with a new intraoperative radiofrequency ablation catheter

BACKGROUND

To assess the efficacy of a new catheter for intraoperative radiofrequency ablation.

METHODS

We operated 35 mitral patients with atrial fibrillation of which 27 had chronic atrial fibrillation with a mean duration of 8 +/- 6 years. Most patients were in functional class III or IV. All patients were operated under cardiopulmonary bypass using sternotomy in 29 patients, right thoracotomy in 5 and left thoracotomy in 1.

RESULTS

Bilateral pulmonary vein isolation with radiofrequency catheter ablation was achieved in 7 +/- 4 minutes. There was no mortality or morbidity. Out of the 27 patients with one to three months follow-up 60% were out of atrial fibrillation and 48% had both atria contracting (scores 3 and 4). A longer time is required to assess the end result of these techniques, because the complete healing of the ablation lesions takes 3 to 6 months.

CONCLUSIONS

We conclude that with appropriate tools and settings the use of intraoperative radiofrequency catheter ablation is fast, safe and effective. Its indications can be extended to other types of atrial fibrillation patients.

[Time integral of oxygen pulse for exercise submaximal levels in patients with heart insufficiency--correlation with maximal oxygen consumption]

Maximal oxygen consumption (VO2max) has an important prognostic value in patients with congestive heart failure (CHF). However, it requires a maximal exercise test, not often available for these patients. To overcome this limitation, we examined whether a simple time integral of oxygen pulse (OP) to submaximal exercise levels correlates with VO2max.

METHODS

We performed a maximal symptom-limited treadmill exercise test, while measuring breath-by-breath oxygen consumption, using the CAEP protocol, in 24 patients with CHF (51 +/- 11 years, 18 males, sinus rhythm). No exercise was terminated due to ischemia or arrhythmias. All patients attained anaerobic threshold. Besides standard parameters, OP (ml) and time integral of OP (OPTI) were calculated at 2 minutes (OP-2 min and OPTI-2 min) and at 4 minutes (OP-4 min and OPTI-4 min) of exercise. Patients were divided in two groups according to VO2max: group I--VO2max > or = 16 ml/kg/min (14 patients) and group II--VO2max < 16 (10 patients).

RESULTS

Age, sex, body surface and CHF etiology were similar in both groups. Exercise duration, maximal OP, time to anaerobic there shold, VO2 and OP at anaerobic there shold were higher in group I (p < 0.05). Comparing group I vs group II--OP-2 min: 6.2 +/- 1.5 vs 5.0 +/- 1.2 ml (p = 0.026); OP-4 min: 7.6 +/- 1.9 vs 5.4 +/- 1.2 (p = 0.001); OPTI-2 min: 3.1 +/- 1.1 vs 2.2 +/- 0.9 (p = 0.021) and OPTI-4 min: 15.2 +/- 4.4 vs 9.3 +/- 3.1 (p = 0.0007). The best correlation with VO2max was obtained for OPTI-4 min (r = 0.696). An OPTI-4 min value > or = 10 occurred in 13 patients of group I and in two patients of group II (p = 0.00013), with a predictive value of 87% for VO2max > 16 (sensitivity = 93%, specificity = 80%)--kappa index = 0.739.

CONCLUSIONS

OPTI-4 min can be a useful tool for assessing cardiocirculatory functional status in patients with CHF and unable to perform a maximal exercise test.

Imerslund-Gräsbeck syndrome in an African patient

Imerslund-Gräsbeck syndrome (IGS) is a rare cause of megaloblastic anaemia in young children. We wish to report the first case described from Africa. The diagnosis of IGS was made on the findings of a low vitamin B12 level, mild proteinuria, and a vitamin B12 absorption test unaffected by the intrinsic factor. The patient responded well to treatment with intramuscular vitamin B12.

[Cardiovascular morbidity in children with human immunodeficiency virus infection]

Abnormalities of cardiovascular structure and function have been described among children with human immunodeficiency virus (HIV). In order to evaluate their occurrence and clinical predictors, 32 children infected with HIV, aged three months to 13 years (mean age = 3.11 +/- 3.51 years) were studied. Perinatal transmission was identified in 90% of the children. Twenty-two patients (pts) (69%) had symptoms, nine being moderately symptomatic and eight severely symptomatic. Fourteen pts had immunological disturbances and eight of them were severely immunosuppressed. Twenty-eight pts (88%) had HIV-1 infection and 6 recent Ebstein-Barr virus coinfection. Nineteen were on zidovudine and 14 on intravenous immunoglobulin treatment. Nineteen cardiovascular abnormalities were found in 15 pts (47%): 11 cases of pulmonary hypertension by echocardiographic criteria (eight of them had interstitial lung infiltrates seen on chest X-ray) and four cases of left ventricular dysfunction requiring anticongestive therapy. Other abnormalities were: patent ductus arteriosus, septal hypertrophy, mitral valve prolapse and pericardial effusion (one case each). Surface ECG displayed right ventricular hypertrophy in four pts, left ventricular hypertrophy in one patient and unspecific ST-T wave changes in two pts. Fourteen pts (44%) had sinus tachycardia with mean heart rate above the 95th percentile on 24-hour Holter monitoring.

CONCLUSIONS

Cardiovascular abnormalities are frequent among children with HIV-1 infection in late stages; pulmonary hypertension is the most frequently found cardiovascular anomaly and seems to be related to either chronic or recurrent respiratory disease; cardiological follow-up is recommended for HIV-infected children.

[Can the ventilatory equivalent for carbon dioxide predict the severity of functional impairment in patients with cardiac insufficiency?]

OBJECTIVE

To evaluate whether the changes in the ventilatory equivalent for carbon dioxide (VE/VCO2), during the early stages of cardiopulmonary exercise testing, can predict maximal oxygen consumption (VO2max) in patients with chronic heart failure.

METHODS

We studied 38 patients (30 males, mean age 56 +/- 11 years) with chronic heart failure. All patients performed maximal symptom limited, treadmill exercise test with breath-by-breath respiratory gas analysis. They were divided in two groups according to their maximal oxygen consumption (group I-VO2max above 14 ml/kg/min and group II-VO2max below 14 ml/kg/min). In both groups, we analysed VE/VCO2 at rest, at the anaerobic threshold (AT) and at peak exercise, and the percentage of VE/VCO2 reduction from rest to AT.

RESULTS

Eleven patients had a VO2max below 14 ml/kg/min (group II). At rest VE/VCO2 = 53 +/- 13 in group II versus 47 +/- 10 in group I (p = 0.048), at the AT VE/VCO2 = 46 +/- 12 in group II versus 36 +/- 7 in group I (p = 0.001) and at peak exercise VE/VCO2 = 46.2 +/- 13 in group II versus 36.2 +/- 6 in group I (p = 0.0002). There was a 24% reduction in the VE/VCO2, from rest to AT in group I, compared to a 16% reduction in group II (p = 0.004). A reduction in the VE/VCO2 from rest to AT less than 16% predicted a VO2max below 14 ml/kg/min with a sensitivity of 60% and a specificity of 93%.

CONCLUSIONS

Patients with severe functional impairment have higher values of VE/VCO2 in all exercise stages. A reduction of VE/VCO2 from rest to anaerobic threshold of less than 16% is a high specific predictor of a VO2max below 14 ml/kg/min.

[Recovery of respiratory parameters and oxygen consumption during the recovery phase of cardiopulmonary exercise test in patients with dilated cardiomyopathy]

OBJECTIVE

To analyse the recovery of oxygen consumption (VO2), ventilation (VE) and carbon dioxide production (VCO2) after maximal cardiopulmonary exercise testing, and to assess the possibility of recovery parameters becoming new markers of functional impairment.

METHODS

Thirty-eight patients (30 males, mean age 56 +/- 11 years) with dilated cardiomyopathy performed maximal, symptom limited, treadmill exercise test with breath-by-breath respiratory gas analysis. The patients were divided in two groups, according to maximal oxygen consumption above or below 14 ml/kg/min (group I and group II, respectively). During the recovery, we analyzed the time to reach 50% of the maximal values of VO2 (T1/2 r VO2), VE (T1/2 e VE) and VCO2 (T1/2 r VCO2) in each group.

RESULTS

Twenty-seven patients had a VO2max above 14 ml/kg/min (group I) and 11 had a VO2max below 14 ml/kg/min (group II). The results were as follows: T1/2 r VO2max 109 +/- 21 sec in group I versus 177 +/- 79 sec in group II (p = 0.0001). T1/2 r VCO2max 124 +/- 28 sec in group I versus 201 +/- 88 sec in group II (p = 0.0001) and T1/2 rVEmax 146 +/- 47 sec in group I versus 229 +/- 47 sec in group II (p = 0.0002).

CONCLUSIONS

Patients with a poor functional capacity show a delay in the half recovery times of oxygen consumption, ventilation and carbon dioxide production. These data suggest that these parameters may be used as new markers of the level of functional impairment.

Quantification of total chromium and hexavalent chromium in UHT milk by ETAAS

Procedures for the quantification of total chromium and hexavalent chromium in UHT milk samples are presented. Total chromium was determined directly in milk with the addition of a surfactant and a mixture of Pd and Mg as a chemical modifier. For the selective separation of hexavalent chromium, the sample pre-treatment consisted in precipitation of proteins and elution of the supernatant through a Chromabond NH2 column. The metal was eluted with nitric acid. Both total chromium and hexavalent chromium were evaluated by atomic absorption spectrometry with electrothermal atomization using the same instrumental conditions. The detection limits were 0.2 and 0.15 microgram l-1 for total chromium and hexavalent chromium, respectively. The linearity ranges under the optimized conditions were 0.2-20 and 0.15-50 micrograms l-1. For total chromium the precision was 4.9 and 5.7% for the analytical and the over-all procedure, respectively, and for hexavalent chromium 4.3 and 4.9%, respectively. The validation of both procedures was performed by the standard additions method and the recoveries were higher than 93% in all cases. For total chromium, a certified reference material was also used to validate the methodology. The methods were applied to the determination of total chromium and hexavalent chromium in 60 UHT milk samples.

Neoadjuvant chemotherapy followed by radical hysterectomy and postoperative adjuvant chemotherapy in the treatment of carcinoma of the cervix uteri: long-term follow-up of a pilot study

OBJECTIVE

The aim of the study was to determine if ACH given after NCH followed by RH could decrease the incidence of distant metastases in patients with locally advanced carcinoma of cervix uteri.

MATERIAL

56 pts (34 Ib, 18 IIb, 4 IIIb) with confirmed diagnosis of squamous cervical cancer were enrolled in this phase II trial. The methodology used was: 1) Figo clinical staging; 2) Ultrasonographic determination of tumor volume in < or > 4 cms; 3) V.B.P. scheme: cis-platinum 50 mg/m2/day 1; vincristine 1 mg/m2/day 1; bleomycin 25 mg/m2/days 1-2-3 (3 courses with 10 days interval); 4) Clinical and sonographic tumor response evaluation following U.I.C.C. response criteria; 5) Radical hysterectomy; 6) Pathological risk factor evaluation; 7) ACH with P.M.C. (cis-platinum 50 mg/m2, methotrexate 30 mg/m2, cyclophosphamide 500 mg/m2) 3 courses every 21 days; 8) Comparison and location of recurrences with a neoadjuvant group (NCH + RH + RT to whole pelvis), and with a control group treated with conventional radiotherapy were done. For statistical analysis the Chi-Square was used and D.F.S. and overall survival (O.S.) were calculated according to the Kaplan Meier and Log Rank Test.

RESULTS

After a median follow-up of 75 months (range 42-108), O. S. for stage Ib was 88%, Stage IIb 78%, and 50% for IIIb. The recurrences were 12% (4/34) for Stage Ib (3 local and 1 distant); 28% for IIb (5/18) (4 pelvic and 1 distant); 50% (2/4) for IIIb (2 pelvic recurrences). When residual tumor volume was < 2 cm in the surgical specimen (n=39) there were 4 recurrences (3 pelvic and 1 distant), and 7 (6 pelvic and 1 distant) for tumors > 2 cm. (p<0.01 for pelvic recurrences). For the stage Ib with residual tumor <2 cm (n=14) there were no pelvic recurrences and only 1 distant. Comparing for Stage Ib with previous tumor volume >4 cm of the ACH Group (n=17) with a classical NCH (n=51) and control (n=51) groups, there were observed 2 (11.7%) pelvic and 1 (5,8%) distant relapses for the 1st Group, 3 (5.9%) pelvic and 3 (5.9%) distant relapses for the 2nd, and 11 (21.6%) pelvic and 5 (9.8%) distant relapses for the 3rd Group. From the comparison of locally advanced tumors (Stages IIb + IIIb) of ACH group (n=22), with a Stage IIIb surgically removed of classical NCH group (n=38) and with a control group of conventional RT (n=51), there were observed 6 (27%) pelvic and 1 (4.5%) distant relapses for the 1st Group, 4 (11%) pelvic and 7 (18.4%) distant relapses for the 2nd, and 31 (60.7%) pelvic and 5 (9.8%) distant for the 3rd one.

CONCLUSION

ACH after NCH + RH could be used for stage Ib with tumor volume > 4 cm, with complete clinical response or residual tumor < 2 cm. The results of this group of tumors suggest the importance of going on phase III trials comparing NCH+RH alone vs. NCH+RH+ACH. ACH could also be used to try to obtain better control of distant metastases in Stages IIb and IIIb. In these cases radiotherapy to the whole pelvis must not be excluded.

[Prenatal cardiology. Suspicion to confirmation]

The mortality rate is high and prognosis is worse among new-borns with prenatal diagnosis of heart malformation, mainly due to factors such as its association with other malformations, and a range of more severe diseases probably resulting from the predominance of the obstetric use of the four chamber view. In this study we retrospectively assessed the range of cardiopathies diagnosed by foetal echocardiography and their evolution, compared with previous years. From January 1994 to December 1995, 1173 foetal echocardiograms were performed at a gestation age of 24 weeks. Sixty-one foetuses (5.2%) had cardiac anomalies, structural in 56 and arrhythmia in 5. The risks and indications were maternal in 37%, foetal in 31%, familial in 17% and environmental in 15%. Three were false negatives (VSD:2; truncus arteriosus: 1). Five died in utero, and 18 were assessed after birth with a mean gestational age of 37 weeks and birth weight of 3 Kg, a caesarean section was performed in 9. All but one were born in central hospitals. Six children were operated on. Two children died, one after surgery. Compared with the four previous years of activity, indication due to foetal risk rose from 6 to 31%, the number of cases diagnosed with heart disease increased from 14 to 30 per year, and the mortality decreased from 59 to 11%. Despite this, we still observe that the vast majority of new-borns who are hospitalised due to a severe heart disease had no prenatal diagnosis, indicating the need to continue our educational policy in this field.

Umbilical hernia of stomach

Herniation of the stomach through the umbilicus is exceedingly rare with only one case reported in the international literature in the past 40 years. One case of a reducible gastric umbilical hernia, not diagnosed by endoscopy, is reported. Diagnosis was made by double-contrast barium examination after 5 years of symptoms and ineffective treatment. Herniation of the stomach is difficult to diagnose by endoscopy and radiological studies can be more sensitive and allow a more specific diagnosis.

Effects of creatine supplementation on body composition, strength, and sprint performance

PURPOSE

To determine the effects of 28 d of creatine supplementation during training on body composition, strength, sprint performance, and hematological profiles.

METHODS

In a double-blind and randomized manner, 25 NCAA division IA football players were matched-paired and assigned to supplement their diet for 28 d during resistance/agility training (8 h x wk[-1]) with a Phosphagen HP (Experimental and Applied Sciences, Golden, CO) placebo (P) containing 99 g x d(-1) of glucose, 3 g x d(-1) of taurine, 1.1 g x d(-1) of disodium phosphate, and 1.2 g x d(-1) of potassium phosphate (P) or Phosphagen HP containing the P with 15.75 g x d(-1) of HPCE pure creatine monohydrate (HP). Before and after supplementation, fasting blood samples were obtained; total body weight, total body water, and body composition were determined; subjects performed a maximal repetition test on the isotonic bench press, squat, and power clean; and subjects performed a cycle ergometer sprint test (12 x 6-s sprints with 30-s rest recovery).

RESULTS

Hematological parameters remained within normal clinical limits for active individuals with no side effects reported. Total body weight significantly increased (P < 0.05) in the HP group (P 0.85 +/- 2.2; HP 2.42 +/- 1.4 kg) while no differences were observed in the percentage of total body water. DEXA scanned body mass (P 0.77 +/- 1.8; HP 2.22 +/- 1.5 kg) and fat/bone-free mass (P 1.33 +/- 1.1; HP 2.43 +/- 1.4 kg) were significantly increased in the HP group. Gains in bench press lifting volume (P -5 +/- 134; HP 225 +/- 246 kg), the sum of bench press, squat, and power clean lifting volume (P 1,105 +/- 429; HP 1,558 +/- 645 kg), and total work performed during the first five 6-s sprints was significantly greater in the HP group.

CONCLUSION

The addition of creatine to the glucose/taurine/electrolyte supplement promoted greater gains in fat/bone-free mass, isotonic lifting volume, and sprint performance during intense resistance/agility training.

Temporal hemodynamic effects of permissive hypercapnia associated with ideal PEEP in ARDS

The associated use of permissive hypercapnia (PHY) and high PEEP levels (PEEP(IDEAL)) has been recently indicated as part of a lung-protective-approach (LPA) in acute respiratory distress syndrome (ARDS). However, the net hemodynamic effect produced by this association is not known. We analyzed the temporal hemodynamic effects of this combined strategy in 48 patients (mean age 34 +/- 13 yr) with ARDS, focusing on its immediate (after 1 h), early (first 36 h), and late (2nd-7th d) consequences. Twenty-five patients were submitted to LPA--with the combined use of permissive hypercapnia (PHY), VT < 6 ml/kg, distending pressures above PEEP < 20 cm H2O, and PEEP 2 cm H2O above the lower inflection point on the static inspiratory P-V curve (P(FLEX))- and 23 control patients were submitted to conventional mechanical ventilation. LPA was initiated at once, resulting in an immediate increase in heart rate (p = 0.0002), cardiac output (p = 0.0002), oxygen delivery (DO2l, p = 0.0003), and mixed venous Po2 (p = 0.0006), with a maintained systemic oxygen consumption (p = 0.52). The mean pulmonary arterial pressure markedly increased (mean increment 8.8 mm Hg; p < 0.0001), but the pulmonary vascular resistance did not change (p = 0.32). Cardiac filling pressures increased (p < 0.001) and the systemic vascular resistance fell (p = 0.003). All these alterations were progressively attenuated in the course of the first 36 h, despite persisting hypercapnia. Plasma lactate suffered a progressive decrement along the early period in LPA but not in control patients (p < 0.0001). No hemodynamic consequences of LPA were noticed in the late period and renal function was preserved. A multivariate analysis suggested that these acute hyperdynamic effects were related to respiratory acidosis, with no depressant effects ascribed to high PEEP levels. In contrast, high plateau pressures were associated with cardiovascular depression. Thus, as long as sufficiently low distending pressures are concomitantly applied, the sudden installation of PHY plus PEEP(IDEAL) induces a transitory hyperdynamic state and pulmonary hypertension without harmful consequences to this young ARDS population.

Severe acute liver failure as the initial manifestation of haematological malignancy

Acute liver failure is rarely secondary to lymphoma or leukaemia and it is extremely uncommon as the initial presentation of malignancy. We report a case of a young adult patient with severe acute liver failure referred for liver transplant, in which a Burkitt acute lymphoblastic leukaemia was diagnosed by bone marrow examination. A complete recovery and long remission were obtained with chemotherapy.

Long-term follow-up of the first randomized trial using neoadjuvant chemotherapy in stage Ib squamous carcinoma of the cervix: the final results

OBJECTIVE

To determine if three courses consisting of 50 mg/m2 cis-platinum, 1 mg/m2 vincristine, and 25 mg/m2 bleomycin (day 1-3) at 10-day intervals can improve survival before Wertheim-Meigs + radiotherapy.

MATERIAL

Two hundred five unselected stage Ib patients (having tumors > 2 cm in diameter) were divided into two groups at random: (1) The group control consisted of 103 patients (56 bulky, > 4 cm diameter) treated with Wertheim-Meigs (if the tumor was resectable with free surgical margins) + adjuvant radiotherapy to whole pelvis (extended field radiation was used only in patients with paraaortic lymph node metastases). When the tumor was unresectable, a surgical staging was performed and radiotherapy was the chosen treatment. (2) Neoadjuvant (102 patients, 61 bulky) had neoadjuvant chemotherapy and then the same treatment as the control patients.

RESULTS

After 67 (31-102) months of follow-up, no difference was seen in tumors > 2 and < 4 cm in both groups (C = 77% vs N = 82%), but statistically significant differences were seen in survival and disease-free survival, in bulky tumors, and between patients with neoadjuvant chemotherapy + Wertheim-Meigs + radiotherapy (80%) and the control (61%). This was due to an increased operability that was substantially improved in bulky tumors in the neoadjuvant chemotherapy group (61/61, 100%) vs control (48/56, 85%; P < 0.01). After 7 years of follow-up, the outcome of the unresectable bulky control group of patients is significantly worse (14%) than that of the resectable group (69%; P < 0.001). With regard to recurrences, a significant decrease in pelvic failures in the neoadjuvant chemotherapy group was observed (P < 0.001). Survival was improved in bulky resectable cases (N = 81% vs C = 69%, P < 0.05). Pathological findings for the surgical specimens revealed differences between both groups because all the risk factors such as parametrial and lymph node metastases, tumor bulk, and vascular embolism had been decreased (P < 0.001).

CONCLUSION

Neoadjuvant chemotherapy can improve survival because of increased operability with free survival margins and a decrease in pathologic risk factors in unselected, bulky (> 4 cm diameter) stage Ib patients.

[Initial assessment of heart murmurs in children: role of complementary diagnostic tests]

Heart murmur, most of them innocent, are the most common reason for referrals to a pediatric cardiologist.

OBJECTIVE

The objective of this study was to analyse the utility of the electrocardiogram (ECG) and echocardiography in the initial assessment of heart murmurs in an asymptomatic pediatric population.

MATERIAL AND METHODS

For each of 170 consecutive children who were seen for first time evaluation of a heart murmur, the clinical diagnosis was registered and the patients were classified as having innocent murmur (IM), pathologic murmur (PM), or possible pathologic murmur (PPM). The results of ECG and echocardiogram two-dimensional/Doppler were registered and changes in diagnosis were recorded and compared with the original impressions.

RESULTS

After ECG no diagnosis was changed. After two-dimensional/Doppler echocardiogram the clinical diagnosis of innocent murmur in 118 children was changed to pathologic in one (one trivial pulmonary stenosis); pathologic murmurs in 43 children was changed to innocent in two; and possible pathologic in nine children was changed to innocent in six and possible pathologic in three. The clinical examinations had a sensitivity of 97.6%, specificity of 93.6%, positive predictive value of 95.3%, and negative predictive value of 99.1%.

CONCLUSIONS

Clinical assessment by a Pediatric Cardiologist is sufficient to distinguish pathologic from innocent heart murmurs. Echocardiography, although diagnostic when heart disease is suspected, is unnecessary in a pediatric patient with clinically diagnosed innocent murmur.