Tracheostomized children tracheal colonization and antibiotic resistance profile - A STROBE analysis

AIMS

To verify the prevalence of Potentially pathogenic bacteria (PPB) and their antimicrobial resistance profile in tracheal aspirates of children with tracheostomy and compare it to clinical data.

METHODS

A cross-sectional study was conducted in patients aged 0-18 years who all underwent tracheostomy cannula change (TCC) performed by the Otolaryngology Unit at Hospital de Clínicas de Porto Alegre, Brazil, between October, 2017 and December, 2018. Patients were submitted, at the time of TCC, to a tracheal aspirate through the tracheostomy and secretion was sent to microbiological analysis and antimicrobial susceptibility testing. Clinical data were evaluated through available patients' electronic medical records.

RESULTS

Forty-four patients had their tracheostomy aspirate cultured and all but one presented PPB growth (97.7%). Median age was 3 years-old. Pseudomonas aeruginosa was the most prevalent bacteria (56.9%) and it was resistant to gentamycin, amikacin and cefepime in 36%, 28% and 12% of the culture tests, respectively. P. aeruginosa resistance to gentamycin and to cefepime suggested an association with the number of antibiotic classes used in the 12 months before enrollment (both p=0.04) and with 2 or more hospital admissions in the same period (p=0.03 and p=0.02, respectively). Staphylococcus aureus was isolated in 9.1% and there was no MRSA.

CONCLUSION

It was found a 97.7% prevalence of PPB in the cultured aspirates; the most prevalent bacterium was P. aeruginosa and there was no MRSA identification. Data suggest an association between P. aeruginosa antimicrobial resistance with previous use of antibiotic therapy.

Nutritional Assessment and Preparation for Adult Bariatric Surgery Candidates: Clinical Practice

Bariatric surgery (BS) has proven to be highly efficacious in the treatment of obesity and its comorbidities. However, careful patient selection is critical for its success. Thus, patients should undergo medical, behavioral, and nutritional assessment by a multidisciplinary team. From the nutritional point of view, BS candidates should undergo nutritional assessment, preparation, and education by a registered dietitian in the preoperative period. Currently, detailed specified and comprehensive information on these topics is lacking. The present narrative review aimed to summarize the available literature concerning both the preoperative nutritional assessment components and the preoperative nutritional preparation and education components of patients planning to undergo BS. Current literature indicates that proper management before BS should include a comprehensive nutritional assessment, in which it is advisable to perform a clinical interview to assess patients' medical background, weight management history, eating patterns and pathologies, oral health, physical activity habits, nutritional status, supplementation usage, BS knowledge, surgery expectations and anthropometric measurements. Nutritional preparation and educational strategies should include an individualized preoperative weight-loss nutrition program, improvement of glycemic control, micronutrients deficiencies correction, eating and lifestyle habits adaptation, physical activity initiation, and strengthening knowledge on obesity and BS. At this stage, more well-designed intervention and long-term cohort studies are needed in order to formulate uniform evidence-based nutritional guidelines for patients who plan to undergo BS, including populations at higher nutritional risk. Moreover, postoperative outcomes of presurgical nutritional intervention programs should be studied.

Abstract P6-03-06: Androgen supplementation in patient derived xenografts in androgen receptor positive breast cancer to increase engraftment and growth rate

Background:

The European fund for regional development (EFRE) supported Precision Oncology and Personalized Therapy Prediction (POP) Project is establishing preclinical models to further the development of personalized therapy options. In the subgroup breast cancer the current goal is to increase the growth and engraftment rates of breast cancer patient derived xenografts (PDX) models.

Methods:

Breast cancer patients of the Department of Gynecology with Breast Center Charité Universitätsmedizin Berlin, Germany are recruited since May 2017. In total 29 tissue samples were collected and included so far.

Treatment naive and treatment refractory patients, tripple negative breast cancer (TNBC), hormone receptor positive (HR+) and Her2 postivie tumors, primary disease, recurrence or metastasis are sampled. Fresh tumor tissue is extracted via surgery or biopsy. The materials are then implanted into female immunodeficient NOG mice. To establish PDX models for HR+ breast cancer the mice received estrogen supplementation.

To increase engraftment and growth rates androgen receptor (AR) testing and subsequently androgen replacement was started since April 2018.

Up to date, 6 new samples have been collected. One HR+ and two TNBC samples tested also positive for AR. These samples are currently in passage 0 (p0) and are now supplied with androgens to increase engraftment and growth rate. One already established AR+ TNBC PDX is being regrown with androgen supplementation to compare growth rates.

Results:

Out of the initial 23 tissue samples ten (six HR+ and four TNBC) have been able to be engrafted into PDX mice.

The TNBC PDX models are one in p1, one in p2, one in p3 and one is being tested with systemic therapy. Engraftment time in p1 were between 19 and 97 days. Growth time to passagable size between 21 and 112 days.

The HR+ PDX models are four in p1 and two in p2. Engraftment time in p1 was between 26 and 123 days. Growth time to passagable size has been achieved in 2 HR+ PDX within 17 to 48 days.

The engraftment/growth rates and times of the androgen supplemented PDX models will be presented.

Conclusion:

Breast cancer growths in humans slowly and this is also the case in the PDX models. To achieve faster growth and higher engraftment rates androgen supplementation in AR+ breast cancer might be an additional enhancive factor.

Citation Format: Kiver VII, Wulf-Goldenberg A, Jurmeister PS, Schweiger C, Gorea O, Hoffmann J, Denkert C, Keilholz U, Liedtke C, Blohmer J-U. Androgen supplementation in patient derived xenografts in androgen receptor positive breast cancer to increase engraftment and growth rate [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-03-06.

Nutritional Management for Chronic Kidney Disease Patients who Undergo Bariatric Surgery: A Narrative Review

Bariatric surgery (BS) may be effective for chronic kidney disease (CKD) patients by reducing microalbuminuria and proteinuria, and by facilitating their meeting inclusion criteria for kidney transplantation. However, nutritional management for this population is complex and specific guidelines are scarce. A literature search was performed to create dietetic practice for these patients based on the most recent evidence. For the purposes of nutritional recommendations, we divided the patients into 2 subgroups: 1) patients with CKD and dialysis, and 2) patients after kidney transplantation. Before surgery, nutritional care includes nutritional status evaluation and adjusting doses of supplements to treat deficiencies and daily nutrient intake according to the dietary restrictions derived from kidney disease, including quantities of fluids, protein, phosphorus, potassium, and vitamins. After BS, these patients are at major risk for lean body mass loss, malnutrition and dehydration because of fluid restriction and diuretics. Postoperative nutritional recommendations should be carefully tailored according to CKD nutritional limitations and include specific considerations regarding protein, fluids, and supplementation, in particular calcium, vitamin A, and vitamin D. Nutritional management of CKD and kidney transplant patients undergoing BS is challenging and future studies are required to establish uniform high-level evidence-based guidelines.

Azidothymidine (AZT) in the Treatment of Symptomatic HIV-1-Infected Hemophiliacs

Twenty-one immunodeficiency virus 1 (HIV 1)-positive hemophilic patients were treated with Azidothymidine (AZT) for symptomatic HIV infection. The median observation period was 20.5 months.

At 25 months the probability of survival was 82%, the probability of progression of disease from CDC III or IV C2 to IV C1 (AIDS) was 20% in patients on continuous AZT treatment and 50% in patients with intermption of treatment. Three patients developed severe leukopenia and 3 patients severe anemii during AZT treatment. In 1 patient a dose-dependent striking increase of transaminases during AZT treatment was observed. In 7 patients treatment was intermpted, in 1 patient because of anemia, in 1 because of pruritus and in 5 patients because of noncompliance.

No signiticant changes in the consumption of clotting factor concentrates and number of bleeding episodes before and during AZT treatment were noted.

We conclude, that both hematological and non-hematological side effects of AZT in HIV 1-infected hemophilic patientr ur. comparable to those seen in other risk groups . AzT does not increase the bleeding tendency in this patient group.

Nutritional Recommendations for Adult Bariatric Surgery Patients: Clinical Practice

Bariatric surgery is currently the most effective treatment for morbid obesity and its associated metabolic complications. To ensure long-term postoperative success, patients must be prepared to adopt comprehensive lifestyle changes. This review summarizes the current evidence and expert opinions with regard to nutritional care in the perioperative and long-term postoperative periods. A literature search was performed with the use of different lines of searches for narrative reviews. Nutritional recommendations are divided into 3 main sections: 1) presurgery nutritional evaluation and presurgery diet and supplementation; 2) postsurgery diet progression, eating-related behaviors, and nutritional therapy for common gastrointestinal symptoms; and 3) recommendations for lifelong supplementation and advice for nutritional follow-up. We recognize the need for uniform, evidence-based nutritional guidelines for bariatric patients and summarize recommendations with the aim of optimizing long-term success and preventing complications.

Roux-en-Y gastric bypass vs sleeve gastrectomy for obese patients with type 2 diabetes: a randomised trial

AIMS/HYPOTHESIS

Bariatric surgery is gaining acceptance as a 'metabolic surgical intervention' for patients with type 2 diabetes. The optimal form of surgery and the mechanism of action of these procedures are much debated. We compared two bariatric procedures for obese patients with type 2 diabetes and evaluated their effects on HbA1c and glucose tolerance.

METHODS

We performed a parallel un-blinded randomised trial of Roux-en-Y gastric bypass (RYGB) vs sleeve gastrectomy (SG) in 41 obese patients with type 2 diabetes, who were bariatric surgery candidates attending the obesity clinic. HbA1c, body composition and glucose tolerance were evaluated at baseline, and at 3 and 12 months.

RESULTS

Of the 41 patients, 37 completed the follow-up (19 RYGB, 18 SG). Both groups had similar baseline anthropometric and biochemical measures, and showed comparable weight loss and fat:fat-free mass ratio changes at 12 months. A similar normalisation of HbA1c levels was observed as early as 3 months post-surgery (6.37 ± 0.71% vs 6.23 ± 0.69% for RYGB vs SG respectively, p < 0.001 in both groups for baseline vs follow-up).

CONCLUSIONS/INTERPRETATION

In this study, RYGB did not have a superior effect in comparison to SG with regard to HbA1c levels or weight loss during 12 months of follow-up.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00667706.

FUNDING

This work was supported by grant no. 3-000-8480 from the Israel Ministry of Health Chief Scientist, the Stephen Morse Diabetes Research Foundation and by Johnson & Johnson.

Preoccupation with death as predictor of psychological distress in patients with haematologic malignancies

The purpose of the present study was to identify preoccupation with death in relation to levels of psychological distress in patients with haematologic malignancies. One hundred and two inpatients with haematologic malignancies, treated with curative intent, and thirty-three control inpatients with benign dysfunction participated in the present study. Psychological distress was measured with the Hospital Anxiety and Depression Scale and the Freiburg Questionnaire of Coping with Illness. Preoccupation with death was assessed with the Subjective Estimation of Sickness and Death Scale. Patients with haematologic malignancies had significantly more preoccupation with death than the control group. In patients with haematologic malignancies preoccupation with death was related to depressive coping style as well as symptoms of depression and anxiety; regression analyses reveal that the diagnosis of haematologic malignancy leads to stronger subjective feelings of being close to death, which in turn leads to more psychological distress. To the best of our knowledge this is the first study that quantitatively shows the existence of preoccupation with death in patients with haematologic malignancies and its association with psychological distress. Our findings indicate that patients who are treated with a curative regime need psychological intervention focusing on death-related fear in order to prevent severe emotional distress.

[Nutritional deficiencies in bariatric surgery patients: prevention, diagnosis and treatment]

The number of people suffering from surgery and obesity in the western world is constantly growing. In 1997 the World Health Organization (WHO) defined obesity as a plague and one of greatest public health hazards of our time. The National Institution of Health (NIH) declared that surgery is the only long-term solution for obesity. Today there are four different types of bariatric surgery. Each variation has different implications on the nutritional status of bariatric surgery patients. Bariatric surgery candidates are at risk of developing vitamin and mineral nutritional deficiencies in the post-operative stage, due to vomiting, decrease in food intake, food intolerance, diminution of gastric secretions and bypass of absorption area. It is easier and more efficient to treat nutritional deficiencies in the preoperative stage. Therefore, preoperative detection and correction are crucial. Blood tests before surgery to detect and treat nutritional deficiencies are crucial. In the postoperative period, blood tests should be conducted every 3 months in the first year after operation, every six months in the second year and annually thereafter. Multivitamin is recommended to prevent nutritional deficiencies in all bariatric surgery patients. Furthermore, iron, calcium, Vitamin D and B12 are additionally recommended for Roux-en-Y Gastric Bypass patients. Patients with Biliopancreatic diversion and Duodenal Switch should also take fat soluble vitamins.

[New insight into old disease: potential treatment of type 2 diabetes mellitus by bariatric surgery]

The incidence of type 2 diabetes mellitus is rising. It presently affects more than 150 million people worldwide, and 7.5% of the population of Europe suffer from this disease. This is partially explained by an increase in the prevalence of obesity. Less than 10% of the diabetic patients achieve appropriate control of their illness. For over a decade, it has been observed that the resolution of type 2 diabetes is an additional outcome of surgical treatment of morbid obesity. Moreover, it has unequivocally been shown that, postoperatively, diabetes-related morbidity and mortality have significantly declined. This improvement in diabetes control is long lasting, and was well documented postoperatively for at least 16 years. Two procedures, the Roux-en-Y gastric bypass (RYGB) and the biliopancreatic diversion (BPD), are more effective treatments for diabetes than other procedures. They are followed by normalization of concentrations of plasma glucose, insulin and glycosylated hemoglobin in 80-100% of morbidly obese patients. Studies have shown that results return to euglycemia and normal insulin levels occur within days after surgery, long before any significant weight loss occurs. This fact suggests that weight loss alone is not a sufficient explanation for this improvement. Other possible mechanisms effective in this phenomenon are decreased food intake, partial malabsorption of nutrients, and anatomical alteration of the gastrointestinal tract, that incites changes in the incretin system, which in turn, affect glucose balance. Better understanding of those mechanisms may lead to the discovery of new treatment modalities for diabetes and obesity.

Nutritional deficiencies in bariatric surgery candidates

BACKGROUND

To assess the prevalence of nutritional deficiencies amongst people who suffer from morbid obesity and are candidates for bariatric surgery and to evaluate the relations between pre-operative nutritional deficiencies and demographic data and co-morbidities.

METHODS

Preoperative blood tests of 114 patients (83 women and 31 men) were collected. The blood tests included plasma chemistry (including albumin, total protein, iron, ferritin, vitamin B12, folic acid, parathyroid hormone (PTH), calcium, and phosphorous) and a blood count (for hemoglobin and mean corpuscular volume (MCV)). Demographic and socio-economic details were collected from all patients.

RESULTS

Mean age, weight, and BMI of the patients were 38 years (15-77), 122.9 kg (87-250), and 44.3 kg/m(2) (35.3-74.9), respectively. The prevalence of pre-operative nutritional deficiencies were: 35% for iron, 24% for folic acid, 24% for ferritin, 3.6% for vitamin B12, 2% for phosphorous, and 0.9% for calcium, Hb and MCV level was low in 19%. High levels of PTH were found among 39% of the patients. No hypoalbuminemia was encountered. Low iron was more common in females relative to men (40.8 vs.14.3%, p = 0.04) as well as ferritin levels (31.8 vs. 0%, p = 0.001). Men showed a greater prevalence of anemia (35.5% and 12% respectively, p = 0.01) relative to women. Patients with BMI > 50 kg/m(2) were at greater risk for low folic acid (OR = 14.57, 95% CI:1.4-151.34). Patients with high income were less likely to have iron deficiency (OR = 0.19, 95% CI:0.038-0.971).

CONCLUSIONS

A high prevalence of nutritional deficiencies was found amongst bariatric surgery candidates suffering from morbid obesity.

Short-term dynamics and metabolic impact of abdominal fat depots after bariatric surgery

OBJECTIVE

Bariatric surgery is gaining acceptance as an efficient treatment modality for obese patients. Mechanistic explanations regarding the effects of bariatric surgery on body composition and fat distribution are still limited.

RESEARCH DESIGN AND METHODS

Intra-abdominal and subcutaneous fat depots were evaluated using computed tomography in 27 obese patients prior to and 6 months following bariatric surgery. Associations with anthropometric and clinical changes were evaluated.

RESULTS

Excess weight loss 6 months following surgery was 47% in male and 42.6% in female subjects. Visceral fat and subcutaneous fat were reduced by 35% and 32%, respectively, in both sexes, thus the visceral-to-subcutaneous fat ratio remained stable. The strongest relation between absolute and relative changes in visceral and subcutaneous fat was demonstrated for the excess weight loss following the operations (r approximately 0.6-0.7), and these relations were strengthened further following adjustments for sex, baseline BMI, and fat mass. Changes in waist circumference and fat mass had no relation to changes in abdominal fat depots. All participants met the criteria of the metabolic syndrome at baseline, and 18 lost the diagnosis on follow-up. A lower baseline visceral-to-subcutaneous fat ratio (0.43 +/- 0.15 vs. 0.61 +/- 0.21, P = 0.02) was associated with clinical resolution of metabolic syndrome parameters.

CONCLUSIONS

The ratio between visceral and subcutaneous abdominal fat remains fairly constant 6 months following bariatric procedures regardless of sex, procedure performed, or presence of metabolic complications. A lower baseline visceral-to-abdominal fat ratio is associated with improvement in metabolic parameters.

Laparoscopic Roux-en-Y gastric bypass for the treatment of morbid obesity: experience with 50 patients

BACKGROUND

Roux-en-Y gastric bypass is currently considered the gold standard surgical option for the treatment of morbid obesity. Open RYGB is associated with a high risk of complications. Laparoscopic RYGB has been shown to reduce perioperative morbidity and improve recovery.

OBJECTIVES

To review our experience with laparoscopic RYGB during a 19 month period.

METHODS

The data were collected prospectively. The study group comprised all patients who underwent laparoscopic RYGB for treatment of morbid obesity as their primary operation between February 2006 and July 2007. The reported outcome included surgical results, weight loss, and improved status of co-morbidities, with follow-up of up to 19 months.

RESULTS

The mean age of the 50 patients was 36.7 years. Mean body mass index was 44.7 kg/m2 (range 35-76 kg/m2); mean duration of surgery was 171 minutes. There was no conversion to open surgery. The mean length of stay was 4 days (range 2-7 days). Five patients (10%) developed a complication, but none of them required early reoperation and there were no deaths. Mean follow-up was 7 months (range 40 days-19 months). The excess body weight loss was 55% and 61% at 6 and 12 months respectively. Diabetes resolved completely or significantly improved in all five patients with this condition, as did hypertension in eight patients out of nine.

CONCLUSIONS

Laparoscopic RYGB is feasible and safe. The results in terms of weight loss and correction of co-morbidities are comparable to other previously published studies. However, only surgeons with experience in advanced laparoscopic as well as bariatric surgery should attempt this procedure.

Leukemia-Derived Dendritic Cells can be Generated from Blood or Bone Marrow Cells from Patients with Acute Myeloid Leukaemia: A Methodological Approach under Serum-Free Culture Conditions

Functional dendritic cells (DC) are professional antigen-presenting cells (APC) and can be generated in vitro from healthy as well as from leukaemic cells from acute myeloid leukemia (AML) patients giving rise to APC of leukaemic origin-presenting leukaemic antigens. We describe the generation and characterization of DC from different mononuclear cell (MNC) fractions from 50 AML patients under different serum-free culture conditions, determine the optimal culture conditions and compare the results with that from 23 healthy donors. In parallel cultures, we compared DC harvests after 7- or 14-day culture, with total or adherent MNC or T-cell depleted MNC or peripheral blood (PB) or bone marrow-MNC (BM-MNC), thawn or fresh MNC, in Xvivo or CellGro serum-free media, +/-10% autologous plasma or +/-FL. In detail, we could show that AML-DC harvests were higher after 10-14 days culture (healthy DC: 7 days); total or adherent PB or BM-MNC fractions yield comparable DC counts, however, from magnetic cell sorting (MACS)-depleted MNC fractions or thawn MNC lower DC counts can be generated. Whereas the addition of FL increases the DC harvest, the addition of autologous plasma in many cases has inhibitory influence on DC maturation. CellGro and Xvivo media yield comparable DC counts. Optimal harvest of vital and mature DC from AML samples was obtained with a granulocyte/macrophage-colony stimulating factor, interleukin-4, FL and tumour necrosis factor-alpha-containing serum-free Xvivo medium after 10-14 days of culture (36/26% DC; 38/64% vital DC; 46/51% mature DC were generated from AML/healthy MNC samples). Surface marker profiles (e.g. costimulatory antigen expressing) of DC obtained from AML samples were comparable with that of healthy DC. The leukaemic derivation of AML-DC was demonstrated by the persistence of the clonal cytogenetic aberration in the DC or by coexpression of leukaemic antigens on DC. Autologous T-cell activation of leukaemia-derived DC was demonstrated in cases with AML. Autologous T cells proliferate and upregulate DC-contact-relevant antigens. We demonstrate that the generation of leukaemia-derived DC is feasable in AML under serum-free culture conditions giving rise to DC with comparable characteristics as healthy DC and offering an anti-leukaemia-directed immunotherapeutical vaccination strategy in AML.

Leukaemia-Derived Dendritic Cells Can Be Generated From Blood or Bone Marrow Cells From Patients With Myelodysplasia: A Methodological Approach Under Serum-Free Culture Conditions

Functional dendritic cells (DC) are professional antigen-presenting cells (APC) and can be generated in vitro from healthy as well as from leukaemic cells from AML patients giving rise to APC of leukaemic origin presenting leukaemic antigens. In a comparative methodological analysis of 50 AML samples, we could already show that leukaemia-derived DC can regularly be generated under serum-free culture conditions. In this study, we describe the generation and characterization of DC from different mononuclear cell (MNC) fractions from 24 myelodysplastic syndrome (MDS) patients under those different serum-free culture conditions, determine the optimal culture conditions and compare the results with that from 23 healthy donors. In parallel cultures, we compared DC harvests after 7- or 14-day culture, with total or adherent MNC or T-cell-depleted MNC or PB or BM-MNC, thawn or fresh MNC, in Xvivo or CellGro serum-free media, +/-10% autologous plasma or +/-FL. In detail, we could show that MDS-DC harvests compared to healthy DC were higher after 10- to 14-day culture; total or adherent PB or BM-MNC fractions yield comparable DC counts; however, from MACS-depleted MNC fractions or thawn MNC lower DC counts can be generated. Whereas the addition of FL increases the DC harvest, the addition of autologous plasma in many cases has inhibitory influence on DC maturation, CellGro and Xvivo media yield comparable DC counts. Optimal harvest of vital and mature DC from MDS samples was obtained with a GM-CSF, IL-4, FL and TNF-alpha containing serum-free Xvivo medium after 10-14 days of culture (18/26% DC; 54/64% vital DC; 59/51% mature DC were generated from MDS/healthy MNC samples). Surface marker profiles (e.g. costimulatory antigen expression) of DC obtained from MDS samples were comparable with that of healthy DC. The leukaemic derivation of MDS-DC was demonstrated by the persistence of the clonal cytogenetic aberration in the DC or by coexpression of leukaemic antigens on DC. Autologous T-cell activation of leukaemia-derived DC was demonstrated in cases with MDS. Autologous T cells proliferate and upregulate DC-contact-relevant antigens. We are the first who demonstrate that the generation of leukaemia-derived DC is feasible not only in AML but also in MDS under serum-free culture conditions giving rise to DC with comparable characteristics as healthy DC and offering an antileukaemia-directed immunotherapeutical vaccination strategy in AML and MDS.

Fr�h- und Basisintervention bei Patienten mit schizophrenen St�rungen

THEORETICAL BACKGROUND

Of all outpatients with a diagnosis of schizophrenia, 30-40% refuse a psychiatrist's care. For this group of patients the general practitioner holds a key position for such different tasks as detection of prodromal schizophrenia or early warning signs of relapse and identification of risk variables for deteriorating outcome, gatekeeping (referral to specialists or other services), integration, and counseling of key relatives. Fifty percent of GPs are interested in disease-specific medical education programs.

STUDY DESIGN AND METHODS

A control trial examined the changes that participating GPs intended to make in three main topics of the curriculum: (1) changing attitudes (pessimistic outcome expectation, low self-esteem), (2) enhancement of detection skills (prodromal schizophrenia, early warning signs of relapse, and risk factors for poor social and vocational integration), and (3) enhancement of management skills (dosing schemes, motivational interviewing).

RESULTS

In the assessment 2 weeks after the training session, we found significant changes in favor of the trained group in detection and management skills and also improved self-confidence of GPs.

CONCLUSIONS

Problem-oriented and case-based learning strategies should be preferred to lectures in training programs for psychiatric skills in primary care.

Efficacy of n-3 polyunsaturated fatty acids after myocardial infarction: results of GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico

Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardio (GISSI)-Prevenzione was conceived as a population, pragmatic trial on patients with recent myocardial infarctions conducted in the framework of the Italian public health system. In GISSI-Prevenzione, patients were invited to follow Mediterranean dietary habits, and were treated with up-to-date preventive pharmacological interventions. Long-term n-3 PUFA (1 g daily) but not vitamin E (300 mg daily) was beneficial for death and for combined death, nonfatal myocardial infarction, and stroke. All the benefit, however, was attributable to the decrease in risk for overall, cardiovascular, cardiac, coronary, and sudden death. At variance with the orientation of a scientific scenario largely dominated by the "cholesterol-heart hypothesis," GISSI-Prevenzione results indicate n-3 PUFA (virtually devoid of any cholesterol-lowering effect) as a relevant pharmacological treatment for secondary prevention after myocardial infarction. As to the relevance and comparability of GISSI-Prevenzione results, up to 5.7 lives could be saved every 1000 patients with previous myocardial infarction treated with n-3 PUFA (1 g daily) per year. Such a result is comparable to that observed in the Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) trial, where 5.2 lives could be saved per 1000 hypercholesterolemic, coronary heart disease patients treated with pravastatin for 1 yr. The choice of a relatively low-dose regimen (1-g capsule daily) more acceptable for long-term treatment in a population of patients following Mediterranean dietary habits, and the pattern of effects seen in GISSI-Prevenzione (namely, reduction of overall mortality with no decrease in the rate of nonfatal myocardial infarction) all strongly suggest that n-3 PUFA treatment should be considered a recommended new component of secondary prevention. The importance of this combined/additive effect is further suggested by the analyses of the interplay between diet and n-3 PUFA: There is an interesting direct correlation between size of the effect and "correctness" of background diets. It can be anticipated that a conceptual barrier must be overcome: A "dietary drug" should be added to "dietary advice," which remains fundamental to allow this statement to become true in clinical practice.

Antioxidant vitamins and prevention of cardiovascular disease: epidemiological and clinical trial data

Naturally occurring antioxidants such as vitamin E, beta-carotene, and vitamin C can inhibit the oxidative modification of low density lipoproteins. This action could positively influence the atherosclerotic process and, as a consequence, the progression of coronary heart disease. A wealth of experimental studies provide a sound biological rationale for the mechanisms of action of antioxidants, whereas epidemiologic studies strongly sustain the "antioxidant hypothesis." To date, however, clinical trials with beta-carotene supplements have been disappointing, and their use as a preventive intervention for cancer and coronary heart disease should be discouraged. Only scanty data from clinical trials are available for vitamin C. As to vitamin E, discrepant results have been obtained by the Alpha-Tocopherol, Beta Carotene Cancer Prevention Study with a low-dose vitamin E supplementation (50 mg/d) and the Cambridge Heart Antioxidant Study (400-800 mg/d). The results of the GISSI-Prevenzione (300 mg/d) and HOPE (400 mg/d) trials suggest the absence of relevant clinical effects of vitamin E on the risk of cardiovascular events. Currently ongoing are several large-scale clinical trials that will help in clarifying the role of vitamin E in association with other antioxidants in the prevention of atherosclerotic coronary disease.

Assessment of absolute risk of death after myocardial infarction by use of multiple-risk-factor assessment equations: GISSI-Prevenzione mortality risk chart

AIMS

To present and discuss a comprehensive and ready to use prediction model of risk of death after myocardial infarction based on the very recently concluded follow-up of the large GISSI-Prevenzione cohort and on the integrated evaluation of different categories of risk factors: those that are non-modifiable, and those related to lifestyles, co-morbidity, background, and other conventional clinical complications produced by the index myocardial infarction.

METHODS

The 11-324 men and women recruited in the study within 3 months from their index myocardial infarction have been followed-up to 4 years. The following risk factors have been used in a Cox proportional hazards model: non-modifiable risk factors: age and sex; complications after myocardial infarction: indicators of left ventricular dysfunction (signs or symptoms of acute left ventricular failure during hospitalization, ejection fraction, NYHA class and extent of ventricular asynergy at echocardiography), indicators of electrical instability (number of premature ventricular beats per hour, sustained or repetitive arrhythmias during 24-h Holter monitoring), indicators of residual ischaemia (spontaneous angina pectoris after myocardial infarction, Canadian Angina Classification class, and exercise testing results); cardiovascular risk factors: smoking habits, history of diabetes mellitus and arterial hypertension, systolic and diastolic blood pressure, blood total and HDL cholesterol, triglycerides, fibrinogen, leukocytes count, intermittent claudication, and heart rate. Multiple regression modelling was assessed by receiver operating characteristic (ROC) analysis. Generalizability of the models was assessed through cross validation and bootstrapping techniques.

POPULATION AND RESULTS

During the 4 years of follow-up, a total of 1071 patients died. Age and left ventricular dysfunction were the most relevant predictors of death. Because of pharmacological treatments, total blood cholesterol, triglycerides, and blood pressure values were not significantly associated with prognosis. Sex-specific prediction equations were formulated to predict risk of death according to age, simple indicators of left ventricular dysfunction, electrical instability, and residual ischaemia along with the following cardiovascular risk factors: smoking habits, history of diabetes mellitus and arterial hypertension, blood HDL cholesterol, fibrinogen, leukocyte count, intermittent claudication, and heart rate. The predictive models produced on the basis of information available in the routine conditions of clinical care after myocardial infarction provide ready to use and highly discriminant criteria to guide secondary prevention strategies.

CONCLUSIONS AND IMPLICATIONS

Besides documenting what should be the preferred and practicable focus of clinical attention for today's patients, the experience of GISSI-Prevenzione suggests that periodically and prospectively collected databases on naturalistic' cohorts could be an important option for updating and verifying the impact of guidelines, which should incorporate the different components of the complex profile of cardiovascular risk. The GISSI Prevenzione risk function is a simple tool to predict risk of death and to improve clinical management of subjects with recent myocardial infarction. The use of predictive risk algorithms can favour the shift from medical logic, based on the treatment of single risk factors, to one centred on the patient as a whole as well as the tailoring of medical interventions according to patients' overall risk.

[Glossary of terms of management and quality]

The implementation of a quality management system (QMS) in the health-care world is nowadays mandatory. This is a specific request not only of local laws but also of the World Health Organization which recently said that "By the year 2000, there should be structures and processes in all member States to ensure a continuous improvement in the quality of health care". In addition, we are bombarded by demands from patients, physicians, employers and the administration. However a QMS is something new for the medical doctor. We think that the first step to divulge the culture of quality in our field is to have a good knowledge of the specific terminology used in the QMS. This glossary explains the meaning of more than 80 terms related to the QMS.

The consequences of under-use of coronary revascularization; results of a cohort study in Northern Italy

AIM

To assess whether under-use of coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) affects patient outcome.

PATIENTS AND METHODS

A prospective observational study was performed following up a cohort of patients, candidates for a revascularization procedure (either CABG or PTCA) after an index angiogram. A total of 1258 patients, candidates -- according to explicit criteria -- for either CABG or PTCA entered the study enrolled by 16 hospitals located in a Northern Italian region (Lombardia). Information on demographic and clinical characteristics, type of care received (i.e. CABG or PTCA performed Yes/No) and vital status was obtained from revascularization laboratories, patients' hospital medical records and local census offices of the town of patients' residence. The main outcome measure was total unadjusted and adjusted mortality at a minimum follow-up of 9 months after the index cardiac angiogram.

RESULTS

Patients who received CABG or PTCA (n=863) had lower mortality than those who did not (n=350) (4.8% vs 10.6%, P=0.001). This held true after adjustment for relevant risk factors between the two groups such as extent of coronary artery disease, clinical symptoms, and cardiac surgical risk index (adjusted odds ratio=0.48; 95% confidence intervals=0.30--0.77) and after performing a survival analysis (adjusted hazard ratio=0.31; 95% confidence intervals=0.19--0.50).

CONCLUSIONS

Failure to perform a revascularization procedure when it was indicated led, in this study, to a significantly increased mortality showing that under-use of effective procedures may represent a significant quality of care problem even in areas where health care systems are well developed. Although the study was not specifically designed to identify determinants of under-use (i.e. reduced capacity leading to waiting lists, physicians' competence or patients' refusal to undergo a recommended procedure) our data suggest that limited capacity could have been the most important reason. Our findings also provide further evidence of the validity of the RAND method to assess the impact of under-use of coronary revascularization procedures.

Epidemiologic study of use of resources in patients with unstable angina: the EARISA registry. On behalf on the EARISA Investigators (Epidemiologia dell'Assorbimento di Risorse nell'Ischemia, Scompenso e Angina)

AIM

The EARISA Registry was designed to describe diagnostic and therapeutic resources used in Italian cardiology centers for patients with the epidemiologically most relevant cardiac diseases. This article focuses on patients with unstable angina; characteristics associated with invasive procedures were specifically analyzed.

METHODS AND RESULTS

Information was collected over a 2-week period on 1420 patients with unstable angina discharged from 308 cardiology centers. The mean length of stay was 9 +/- 6 days; 51% of patients were admitted to a coronary care unit (mean length of stay, 4 +/- 3 days). Noninvasive procedures included echocardiography (64%), Holter monitoring (25%), exercise stress testing (24%), and echocardiographic stress testing or nuclear imaging (7%). Invasive procedures were coronary angiography (39%) and percutaneous transluminal coronary angioplasty or coronary artery bypass grafting (13%). Unstable angina had a greater impact on invasive procedures than acute myocardial infarction. Variables independently associated with a higher rate of coronary angiographic procedures were younger age, higher technologic level of the hospital, and need for intravenous therapy.

CONCLUSION

In Italy, approximately half the patients with unstable angina are admitted to hospitals without catheterization laboratories or cardiac surgery facilities. This fact supports the concept that treatments that can be administered in all types of hospitals are more likely to affect the outcome of patients with unstable angina. Overall, the rates of coronary angiography and revascularization procedures appeared low, and the setting where cardiologists practice, rather than patient characteristics, is the major determinant of the care given to patients with unstable angina.

Dissociation of allergen-specific IgE and IgA responses in sera and tears of pollen-allergic patients: a study performed with purified recombinant pollen allergens

BACKGROUND

Trees and grass pollen allergens represent potent elicitors of allergic rhinoconjunctivitis and asthma. Little is known regarding the presence of allergen-specific IgA antibodies in sera and tears and their association with IgE responses in patients with allergic conjunctivitis.

OBJECTIVE

The purpose of this study was to compare the specificities of IgE and IgA antibodies in sera and tears of pollen-allergic patients with conjunctivitis by using purified recombinant pollen allergens.

METHODS

Sera and tears collected from 23 pollen-allergic and from 23 nonatopic individuals were analyzed for IgE and IgA reactivity to nitrocellulose-blotted birch and timothy grass pollen extracts. In addition, we determined the specificities of IgE, IgG(1-4), and IgA antibodies with use of a panel of purified recombinant pollen allergens (timothy grass: rPhl p 1, rPhl p 2, rPhl p 5; birch: rBet v 1, rBet v 2) in serum and tear samples by immunoblotting and ELISA. Statistical analyses of data were performed by t test and Mann Whitney U test.

RESULTS

Serum and tears of many of the pollen-allergic individuals with conjunctivitis exhibited specificity for the very same pollen allergens. No allergen-specific IgE antibodies were detected in tears of nonatopic individuals. IgA antibodies in sera and tears of patients with allergic conjunctivitis were mainly directed against nonallergenic moieties and showed specificities that were significantly different from those of IgE antibodies.

CONCLUSION

The dissociation of IgE and IgA responses and the lack of allergen-specific IgA antibodies in mucosal secretions (eg, tears) may contribute to allergic manifestations in target organs of atopy. Induction of allergen-specific IgA antibodies may hence be considered as a promising strategy for the treatment of mucosal forms of atopy.

[The cardiology community and health reform. Some reflections to open a debate]

A recently introduced health care reform in Italy will modify substantially the scenario in which all physicians and also the cardiac specialists working in and out of the hospitals will operate. Therefore it is important that the cardiological community, who manages a large proportion of human and financial resources of the Italian National Health Service, knows the reform and interacts with the national and local authorities for the best implementation of the basic principles on which the reform has been founded. These principles are the following: the Italian health service will guarantee all citizens the so-called "essential levels of care" identified in accordance with four distinctive features. They must: 1) safeguard real needs of care (i.e. cosmetic surgery is not considered), 2) be evidence based, 3) be appropriate for individual patients, 4) be cost-effective. In a context of scarce resources and rapidly increasing demand of care this basic strategy seems to be the only one suitable for a National Health Service, but the application of this principle in the real world of care seems a very difficult task, and the role of medical associations is obviously crucial for a good outcome. This report illustrates some articles of the law that deal with the medical profession: guidelines and appropriateness of the criteria; accreditation, clinical competence and quality control; continuing medical education.

Component-resolved diagnosis (CRD) of type I allergy with recombinant grass and tree pollen allergens by skin testing

The diagnosis of Type I allergy is based on the measurement of allergen-specific IgE antibodies and on provocation with allergens, most frequently conducted by skin testing. Both forms of diagnosis are currently performed with allergen extracts that are difficult to standardize regarding their allergen contents, and which contain additional undefined nonallergenic components. We report the expression in Escherichia coli and purification of some of the most relevant timothy grass- and birch pollen allergens. Recombinant timothy grass- (rPhl p 1, rPhl p 2, rPhl p 5) and birch pollen (rBet v 1, rBet v 2) allergens were purified and used for the measurement of allergen-specific IgE and IgG subclass responses as well as for skin prick testing in 55 pollen allergic patients and 10 nonatopic individuals. Results obtained showed that the recombinant allergens allowed in vivo allergy diagnosis in 52 of 54 of the grass pollen and in 35 of 36 of the birch pollen allergic patients. Positive skin reactions were observed almost exclusively in patients containing detectable allergen-specific IgE antibodies but not in the nonatopic group; however, sensitivity to a given allergen as measured by skin reactivity was weakly correlated with the levels of allergen-specific IgE. Our results demonstrate that recombinant allergens can be used for component-resolved skin test diagnosis (CRD) of the patients' allergen sensitization profile, whereas allergen extracts at best allow to identify allergen-containing sources. CRD may thus represent the basis for novel forms of patient-tailored immunotherapy.

Evaluation of four automated methods for determination of whole blood cyclosporine concentrations

Cyclosporine is a widely used and potent immunosuppressant drug with a narrow therapeutic index. Therefore, cyclosporine concentrations should be monitored closely. Various automated immunologic methods for cyclosporine whole blood determinations are available. Two new methods, fluorescence polarization immunoassay (FPIA) for the AxSYM by Abbott Laboratories, Chicago, IL, and the cloned enzyme donor immunoassay (CEDIA) by Boehringer Mannheim, Mannheim, Germany, have been introduced. In addition, Dade Behring improved its enzyme multiplied immunoassay (EMIT) assay. The present study evaluated all 3 new methods in comparison with high-performance liquid chromatography (HPLC) and the FPIA for the TDx analyzer. We measured whole blood cyclosporine concentrations of 179 samples obtained from 127 patients after kidney, bone marrow, heart-lung, and liver transplantation. All 4 automated immunologic methods can be used for routine measurement of cyclosporine whole blood concentrations. Disadvantages, such as higher cross-reactivity (Abbott TDx, CEDIA) or a limited linearity range (EMIT), are accompanied by advantages, such as a high precision (Abbott TDx) or an easy sample handling procedure (CEDIA). Information presented in this article should help to find the most adequate cyclosporine method for each medical laboratory.

Tropisetron or ondansetron compared with placebo for prevention of postoperative nausea and vomiting

In a prospective, randomized, double-blind, placebo-controlled, multicentre study, the efficacy of prophylactic tropisetron (2 mg) or ondansetron (4 mg) for the prevention of post-operative nausea and vomiting after abdominal or non-abdominal surgery with general balanced anaesthesia was studied in 842 ASA I-III patients. In patients undergoing abdominal surgery, ondansetron and tropisetron reduced the frequency of emetic episodes compared with the placebo (29%, 30% vs. 42% respectively). In men, neither tropisetron nor ondansetron had an effect different from the placebo, whereas in women both drugs led to lower rates of emetic episodes and nausea. In comparison with abdominal surgery, fewer patients in the non-abdominal surgery subgroup had emetic episodes (42% vs. 23% in the placebo group). However, neither tropisetron nor ondansetron was significantly different from the placebo in this patient subgroup. In conclusion, for patients at increased risk of post-operative nausea and vomiting, a prophylactic therapy at the lowest effective dose with tropisetron or ondansetron may be useful.