Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Impact of Nutritional Stress on Honeybee Gut Microbiota, Immunity, and Nosema ceranae Infection

Honeybees are important pollinators, having an essential role in the ecology of natural and agricultural environments. Honeybee colony losses episodes reported worldwide and have been associated with different pests and pathogens, pesticide exposure, and nutritional stress. This nutritional stress is related to the increase in monoculture areas which leads to a reduction of pollen availability and diversity. In this study, we examined whether nutritional stress affects honeybee gut microbiota, bee immunity, and infection by Nosema ceranae, under laboratory conditions. Consumption of Eucalyptus grandis pollen was used as a nutritionally poor-quality diet to study nutritional stress, in contraposition to the consumption of polyfloral pollen. Honeybees feed with Eucalyptus grandis pollen showed a lower abundance of Lactobacillus mellifer and Lactobacillus apis (Firm-4 and Firm-5, respectively) and Bifidobacterium spp. and a higher abundance of Bartonella apis, than honeybees fed with polyfloral pollen. Besides the impact of nutritional stress on honeybee microbiota, it also decreased the expression levels of vitellogenin and genes associated to immunity (glucose oxidase, hymenoptaecin and lysozyme). Finally, Eucalyptus grandis pollen favored the multiplication of Nosema ceranae. These results show that nutritional stress impacts the honeybee gut microbiota, having consequences on honeybee immunity and pathogen development. Those results may be useful to understand the influence of modern agriculture on honeybee health.

Evaluation of VIDAS Listeria monocytogenes II (LMO2) Immunoassay Method for the Detection of Listeria monocytogenes in Foods: Collaborative Study

A multilaboratory study was conducted to compare the VIDAS®Listeria monocytogenes II (LMO2) immunoassay and the standard cultural methods for the detection of Listeria monocytogenes in foods. Five food types—vanilla ice cream, brie cheese, cooked roast beef, frozen green beans, and frozen tilapia fish—at 3 levels were analyzed by each method. A total of 26 laboratories representing government and industry participated. In this study, 1404 test portions were analyzed of which 1152 were used in the statistical analysis. There were 448 positive by the VIDAS LMO2 assay and 457 positive by the standard culture methods. A χ2 analysis of each of the 5 food types, at the 3 inoculation levels tested, was performed. The resulting χ2 value, 0.36, indicates that overall, there are no statistical differences between the VIDAS LMO2 assay and the standard methods at the 5% level of significance.

Evaluation of the BAX® System for Detection of Listeria monocytogenes in Foods: Collaborative Study

A multilaboratory study was conducted to compare the automated BAX® system and the standard cultural methods for detection of Listeria monocytogenes in foods. Six food types (frankfurters, soft cheese, smoked salmon, raw, ground beef, fresh radishes, and frozen peas) were analyzed by each method. For each food type, 3 inoculation levels were tested: high (average of 2 CFU/g), low (average of 0.2 CFU/g) and uninoculated controls. A total of 25 laboratories representing government and industry participated. Of the 2335 samples analyzed, 1109 were positive by the BAX system and 1115 were positive by the standard method. A Chi square analysis of each of the 6 food types, at the 3 inoculation levels tested, was performed. For all foods, except radishes, the BAX system performed as well as or better than the standard reference methods based on the Chi square results.

Two amplicon sequencing strategies revealed different facets of the prokaryotic community associated with the anaerobic treatment of vinasses from ethanol distilleries

The prokaryotic consortium from a pilot-scale UASB reactor fed with vinasses from ethanol distilleries was evaluated by means of amplicon sequencing of the 16S rRNA gene. Two different sets of primers targeted to overlapping regions of the V4-16S region were used to gain a broad picture of such community and to perform a comparative analysis. From the two datasets obtained, prevalent phyla were Firmicutes, Verrucomicrobia and Thermotogae. Interestingly, one set of primers captured variability in both the bacterial and archaeal portions of the community, whilst the other one revealed a more diverse community structure, but only in the Bacteria domain. Although a certain level of agreement between the two strategies was observed, sharp differences indicate that different facets of the community were disclosed by each approach.

[Fat composition of several "fast food"]

The percentage of fat of a variety of foods served in fast food establishments has been determined. This percentage is very variable, with mean contents of total fat of 35.83 +/- 10.68% in beef hamburgers, 35.84 +/- 8.66% in chips, 23.02 +/- 5.07% in chicken hamburgers and 34.02 +/- 13.49% in "hot dogs". The lipidic composition is mainly formed by saturated fatty acids (28-52% of total fat) and monounsaturated (46-48%), whereas the proportion of polyunsaturated fatty acids showed more variable values, ranging from 6.9% in beef hamburgers to 25.1% in chips. Statistical treatment of the results of relative percentage of fatty acids by multivariate methods revealed clusters of samples grouped as a function of the type of food and in some instances of its source, which can be interesting in case of healthy problems. Percentages of trans fatty acids slightly higher than the maximum recommended values have been detected in some cases. These results show the urgent need of modifying the laws to force fast food establishments to specify the type and amounts of fat used in the processing of these foods, as well as a greater control from the local administrations.

In vivo dc and ac measurements at acupuncture points in healthy and unhealthy people

OBJECTIVES

The aim of this work was to compare in vivo measurements of direct current (dc) and alternating current (ac) obtained from acupuncture points in Ukrainian and Mexican residents.

METHODS

Measurements were made using the method of Voll. The participants were 43 healthy Ukrainian and 71 healthy Mexican residents aged between 20 and 30 years, as well as 24 Mexican patients with a clinical diagnosis of rheumatoid arthritis and 14 patients with a clinical diagnosis of allergy.

RESULTS

The results showed that dc measurements are not directly applicable to different populations. Thus, the dc resistance of the acupuncture points in the Mexican participants was 4-5 times larger than in the Ukrainians. In contrast, the capacitance of the two groups did not differ by more than 25%.

CONCLUSIONS

Impedance measurements from acupuncture points can be used as an efficient and prompt non-invasive method for diagnostic purposes.

Evaluation of the BAX system for detection of Listeria monocytogenes in foods: collaborative study

A multilaboratory study was conducted to compare the automated BAX system and the standard cultural methods for detection of Listeria monocytogenes in foods. Six food types (frankfurters, soft cheese, smoked salmon, raw, ground beef, fresh radishes, and frozen peas) were analyzed by each method. For each food type, 3 inoculation levels were tested: high (average of 2 CFU/g), low (average of 0.2 CFU/g) and uninoculated controls. A total of 25 laboratories representing government and industry participated. Of the 2335 samples analyzed, 1109 were positive by the BAX system and 1115 were positive by the standard method. A Chi square analysis of each of the 6 food types, at the 3 inoculation levels tested, was performed. For all foods, except radishes, the BAX system performed as well as or better than the standard reference methods based on the Chi square results.

Translational selection on codon usage in Xenopus laevis

A correspondence analysis of codon usage in Xenopus laevis revealed that the first axis is strongly correlated with the base composition at third codon positions. The second axis discriminates between putatively highly expressed genes and the other coding sequences, with expression levels being confirmed by the analysis of Expressed sequence tag frequencies. The comparison of codon usage of the sequences displaying the extreme values on the second axis indicates that several codons are statistically more frequent among the highly expressed (mainly housekeeping) genes. Translational selection appears, therefore, to influence synonymous codon usage in Xenopus.

Translational selection shapes codon usage in the GC-rich genome of Chlamydomonas reinhardtii

In unicellular species codon usage is determined by mutational biases and natural selection. Among prokaryotes, the influence of these factors is different if the genome is skewed towards AT or GC, since in AT-rich organisms translational selection is absent. On the other hand, in AT-rich unicellular eukaryotes the two factors are present. In order to understand if GC-rich genomes display a similar behavior, the case of Chlamydomonas reinhardtii was studied. Since we found that translational selection strongly influences codon usage in this species, we conclude that there is not a common pattern among unicellular organisms.

[Oral nutritional supplements. Are they useful?]

Oral nutritional supplements are products included in enteral nutrition, preferably used in hospital settings, although their use in the community is gradually increasing and in the United Kingdom has doubled in the last seven years, with prescriptions covering a wide range of the population from children to the elderly, and different pathologies affecting their nutritional status. There is, however, no consensus on the usefulness of oral nutritional supplements among these patients, so we do not have any recommendations for use. In this paper we have reviewed the various studies available in the literature in order to clarify the usefulness of these supplements in different contexts or pathologies.

Prevention of group B streptococcus early-onset neonatal sepsis: comparison of the Center for Disease Control and prevention screening-based protocol to a risk-based protocol in infants at greater than 37 weeks' gestation

OBJECTIVE

To compare the Center for Disease Control consensus guidelines' screening-based strategy to a risk-based strategy as regards the incidence of early-onset group B streptococcus (GBS) infection among term infants.

STUDY DESIGN

A cohort of university hospital prenatal clinic mother-infant pairs who were screened for GBS at 35 to 37 weeks' gestation were compared to a matched control group of unscreened mother-infant pairs from the outreach satellite prenatal clinics who delivered at the same institution during the same time period. GBS screening was carried out with rectovaginal cultures plated on selective media. GBS-positive women received antimicrobial prophylaxis in labor whereas women of unknown GBS status were only treated intrapartum if they had a risk factor for GBS infection. Principal outcome variables included incidence of cases of neonatal early-onset GBS sepsis (blood, urine, or cerebrospinal fluid positive for GBS), incidence of cases of strongly suspected GBS sepsis (culture negative), and incidence of neonatal sepsis with non-GBS organisms.

RESULTS

There were 3164 screened mother-infant pairs who were compared to 2684 unscreened pairs. The incidence of GBS carriage was 13.3%. A random sample of 420 screened women were compared to a matched sample of 407 women of unknown GBS carrier status for characterization of demographics and risk factors. No cases of documented GBS sepsis occurred in the infants of the screened women, but four cases occurred among the infants of the women who did not undergo screening (incidence 1.5/1000) (p = 0.04), only one of whom had a risk factor for GBS infection. Cases of suspected but culture negative sepsis were not more common in the screened population when compared to the unscreened. There was one case of Escherichia coli sepsis in an infant of a mother in the unscreened group.

CONCLUSIONS

GBS screening at 35 to 37 weeks, with intrapartum antimicrobial prophylaxis of carriers, decreased the incidence of neonatal early-onset GBS sepsis and appears to have advantages over treatment based on risk factors alone in term infants.

Codon usage in Chlamydia trachomatis is the result of strand-specific mutational biases and a complex pattern of selective forces

The patterns of synonymous codon choices of the completely sequenced genome of the bacterium Chlamydia trachomatis were analysed. We found that the most important source of variation among the genes results from whether the sequence is located on the leading or lagging strand of replication, resulting in an over representation of G or C, respectively. This can be explained by different mutational biases associated to the different enzymes that replicate each strand. Next we found that most highly expressed sequences are located on the leading strand of replication. From this result, replicational-transcriptional selection can be invoked. Then, when the genes located on the leading strand are studied separately, the correspondence analysis detects a principal trend which discriminates between lowly and highly expressed sequences, the latter displaying a different codon usage pattern than the former, suggesting selection for translation, which is reinforced by the fact that Ks values between orthologous sequences from C. trachomatis and Chlamydia pneumoniae are much smaller in highly expressed genes. Finally, synonymous codon choices appear to be influenced by the hydropathy of each encoded protein and by the degree of amino acid conservation. Therefore, synonymous codon usage in C.trachomatis seems to be the result of a very complex balance among different factors, which rises the problem of whether the forces driving codon usage patterns among microorganisms are rather more complex than generally accepted.

Compositional pressure and translational selection determine codon usage in the extremely GC-poor unicellular eukaryote Entamoeba histolytica

It is widely accepted that the compositional pressure is the only factor shaping codon usage in unicellular species displaying extremely biased genomic compositions. This seems to be the case in the prokaryotes Mycoplasma capricolum, Rickettsia prowasekii and Borrelia burgdorferi (GC-poor), and in Micrococcus luteus (GC-rich). However, in the GC-poor unicellular eukaryotes Dictyostelium discoideum and Plasmodium falciparum, there is evidence that selection, acting at the level of translation, influences codon choices. This is a twofold intriguing finding, since (1) the genomic GC levels of the above mentioned eukaryotes are lower than the GC% of any studied bacteria, and (2) bacteria usually have larger effective population sizes than eukaryotes, and hence natural selection is expected to overcome more efficiently the randomizing effects of genetic drift among prokaryotes than among eukaryotes. In order to gain a new insight about this problem, we analysed the patterns of codon preferences of the nuclear genes of Entamoeba histolytica, a unicellular eukaryote characterised by an extremely AT-rich genome (GC = 25%). The overall codon usage is strongly biased towards A and T in the third codon positions, and among the presumed highly expressed sequences, there is an increased relative usage of a subset of codons, many of which are C-ending. Since an increase in C in third codon positions is 'against' the compositional bias, we conclude that codon usage in E. histolytica, as happens in D. discoideum and P. falciparum, is the result of an equilibrium between compositional pressure and selection. These findings raise the question of why strongly compositionally biased eukaryotic cells may be more sensitive to the (presumed) slight differences among synonymous codons than compositionally biased bacteria.

Compositional correlations in the chicken genome

This paper analyses the compositional correlations that hold in the chicken genome. Significant linear correlations were found among the regions studied-coding sequences (and their first, second, and third codon positions), flanking regions (5' and 3'), and introns-as is the case in the human genome. We found that these compositional correlations are not limited to global GC levels but even extend to individual bases. Furthermore, an analysis of 1037 coding sequences has confirmed a correlation among GC(3), GC(2), and GC(1). The implications of these results are discussed.

Synonymous codon choices in the extremely GC-poor genome of Plasmodium falciparum: compositional constraints and translational selection

We have analyzed the patterns of synonymous codon preferences of the nuclear genes of Plasmodium falciparum, a unicellular parasite characterized by an extremely GC-poor genome. When all genes are considered, codon usage is strongly biased toward A and T in third codon positions, as expected, but multivariate statistical analysis detects a major trend among genes. At one end genes display codon choices determined mainly by the extreme genome composition of this parasite, and very probably their expression level is low. At the other end a few genes exhibit an increased relative usage of a particular subset of codons, many of which are C-ending. Since the majority of these few genes is putatively highly expressed, we postulate that the increased C-ending codons are translationally optimal. In conclusion, while codon usage of the majority of P. falciparum genes is determined mainly by compositional constraints, a small number of genes exhibit translational selection.

Ajoene in the topical short-term treatment of tinea cruris and tinea corporis in humans. Randomized comparative study with terbinafine

Ajoene (CAS 92284-99-6), an organic trisulphur originally isolated from garlic, has an antimycotic activity which has been widely demonstrated both in vitro and in vivo. The objective of this work was to compare the safety and effectiveness of ajoene (0.6%, gel) with terbinafine (CAS 91161-71-6) (1%, cream) for the treatment of tinea corporis and tinea cruris. The patients selected were 60 soldiers with clinical and mycological diagnosis of either dermatophytosis. They were distributed at random in two treatment groups, one treated with ajoene at 0.6% and the other with terbinafine at 1%. All patients were evaluated clinically and mycologically 30 and 60 days after completion of the treatment, which was considered effective when clinical signs and symptoms had disappeared and the mycological cultures were negative. Thirty days after treatment, the percent healing rate was 77 and 75 for the groups treated with ajoene and terbinafine, respectively. Sixty days after treatment, the healing rate 73% and 71% for the groups treated with ajoene and terbinafine, respectively. These results and those obtained in previous studies confirm that ajoene is a new agent for the topic treatment of superficial mycoses, and for the first time show the therapeutic usefulness of an inhibitor of phospholipids biosynthesis in eukaryotes.

Pesticides and inner-city children: exposures, risks, and prevention

Six million children live in poverty in America's inner cities. These children are at high risk of exposure to pesticides that are used extensively in urban schools, homes, and day-care centers for control of roaches, rats, and other vermin. The organophosphate insecticide chlorpyrifos and certain pyrethroids are the registered pesticides most heavily applied in cities. Illegal street pesticides are also in use, including tres pasitos (a carbamate), tiza china, and methyl parathion. In New York State in 1997, the heaviest use of pesticides in all counties statewide was in the urban boroughs of Manhattan and Brooklyn. Children are highly vulnerable to pesticides. Because of their play close to the ground, their hand-to-mouth behavior, and their unique dietary patterns, children absorb more pesticides from their environment than adults. The long persistence of semivolatile pesticides such as chlorpyrifos on rugs, furniture, stuffed toys, and other absorbent surfaces within closed apartments further enhances urban children's exposures. Compounding these risks of heavy exposures are children's decreased ability to detoxify and excrete pesticides and the rapid growth, development, and differentiation of their vital organ systems. These developmental immaturities create early windows of great vulnerability. Recent experimental data suggest, for example, that chlorpyrifos may be a developmental neurotoxicant and that exposure in utero may cause biochemical and functional aberrations in fetal neurons as well as deficits in the number of neurons. Certain pyrethroids exert hormonal activity that may alter early neurologic and reproductive development. Assays currently used for assessment of the toxicity of pesticides are insensitive and cannot accurately predict effects to children exposed in utero or in early postnatal life. Protection of American children, and particularly of inner-city children, against the developmental hazards of pesticides requires a comprehensive strategy that monitors patterns of pesticide use on a continuing basis, assesses children's actual exposures to pesticides, uses state-of-the-art developmental toxicity testing, and establishes societal targets for reduction of pesticide use.

Immunohistochemical detection of HSP60-expression in human ovarian cancer. Correlation with survival in a series of 247 patients

PURPOSE

In a previous pilot study, HSP60 expression at the transcriptional (mRNA) level was shown to be a negative prognostic factor in ovarian cancer. The aim of this study was to determine HSP60-expression by means of immunohistochemistry and to correlate the results with survival in a large series of ovarian carcinoma patients with a closed follow-up.

MATERIALS AND METHODS

Slides from routinely processed, paraffin-embedded tumor blocks belonging to 247 patients with epithelial ovarian carcinoma were studied for the overexpression of HSP60 using the Lk2 monoclonal antibody and the strepatvidin-biotin-peroxidase technique. HSP60-expression was correlated with overall survival by means of life-table analysis and the Kaplan-Meier method.

RESULTS

47 tumors (19%) expressed HSP60. Of them, 12/29 (41.4% positivity) were stage I tumors, whereas only 35 out of the remaining 218 tumors in more advanced surgical stage (16.1%) showed HSP60 staining. This difference was statistically significant (Fisher s exact test; p = 0.004). Even when stratifying stage for stage, the difference between groups still remained statistically significant (Chi square test; p = 0.0095). The survival curve analysis showed a significant difference in favor of those tumors expressing HSP60 (median survival 28 vs. 37 months; log-rank test, p = 0.02).

CONCLUSION

Immunohistochemical detection of HSP60-expression in human epithelial ovarian carcinoma is significantly more frequent in tumors from patients with initial stages of the disease. Therefore, HSP60-expression determined by this method is associated with a significantly better prognosis.

[A case of Parkinson syndrome secondary to combined amineptine and bromazepam abuse]

A case report of parkinsonism secondary to chronic abuse of amineptine (3 gr/day) and bromazepam (35 mg/day) in a patient diagnosed of borderline personality disorder is presented. The patient did not take any other drugs and he was not recently on neuroleptic treatment; he recognized the abuse of amineptine, as a stimulant, and the bromazepam abuse, looking for a relief to the excessive anxiety secondary to amineptine. The parkinsonism improved after removing both drugs and taking biperiden and diazepam; lastly the patient was discharged without any medication. The patient did not suffer from other complications associated with amineptine or bromazepam abuse. There are some cases reported of parkinsonism secondary to benzodiazepines but there is none secondary to amineptine. We present a short review of the possible responsible mechanisms, thinking on a complex interaction of both drugs on dopamine and its modulatory systems.

Enteral nutrition by percutaneous endoscopic gastrojejunostomy in severe hyperemesis gravidarum: a report of two cases

We describe the first two cases in which percutaneous endoscopic gastrojejunostomy was used as a means to provide enteral nutrition in severe hypermesis gravidarum. The use of this method of enteral access provided an alternative to parenteral nutrition, was well tolerated, cost-effective and had no major complications. In both cases the nutritional goal for mothers as well as appropriate fetal growth and development were achieved.

Cross-reactivity between Candida albicans and human ovarian carcinoma as revealed by monoclonal antibodies PA10F and C6

Summary Antibodies against Candida albicans antigenic determinants have been reported to cross-react with human tumour cells. We have found that two monoclonal antibodies, C6 and PA1OF, developed at our laboratory against C. albicans antigenic determinants, cross-react with human ovarian cancer on Western blots and immunohistochemistry. We have subsequently used one of them, PA10OF, to test by means of immunohistochemistry a series of 37 human ovarian carcinomas. Out of 37 tumours, 25 (67.6%) expressed the antigen recognized by PA1OF. The reactivity, however, was concentrated on the subgroup of particularly aggressive, invasive carcinomas in advanced stages of the disease (19 out of 24 positive), whereas the antigen was expressed significantly less (P=0.0007) in the subgroup of much less aggressive stage I tumours of low malignant potential, also called borderline carcinomas (2 out of 13 positive). This cross-reactivity between C. albicans and ovarian carcinoma seems to be attributable to a common antigenic determinant related to tumour aggressiveness.

Heterogeneity in codon usage in the flatworm Schistosoma mansoni

Synonymous codon choices vary considerably among Schistosoma mansoni genes. Principal components analysis detects a single major trend among genes, which highly correlates with GC content in third codon positions and exons, but does not discriminate among putatively highly and lowly expressed genes. The effective number of codons used in each gene, and its distribution when plotted against GC3, suggests that codon usage is shaped mainly by mutational biases. The GC content of exons, GC3, 5', 3', and flanking (5' + 3' + introns) regions are all correlated among them, suggesting that variations in GC content may exist among different regions of the S. mansoni genome. We propose that this genome structure might be among the most important factors shaping codon usage in this species, although the action of selection on certain sequences cannot be excluded.

[Percutaneous endoscopic gastrostomy and gastrojejunostomy. Experience and its role in domiciliary enteral nutrition]

Percutaneous Endoscopic Gastrostomy (PEG) and its variation Percutaneous Endoscopic Gastrojejunostomy (PEGJ), has become the method of choice to achieve an enteral access route in patients who require long term enteral nutrition, especially in the area of the At Home Enteral Nutrition (AHEN). We present our experience on the first PEG's and PEGJ's carried out in our hospital.

MATERIAL

We studied 48 patients (14 women and 34 men) in whom a PEG/Percutaneous Endoscopic Gastrojejunostomy (PEGJ) was indicated, as they required enteral nutrition for prolonged periods of time (> 4 weeks) and/or they presented obstructive dysphagia, neuromotor dysphagia, or incorrigible vomiting in the two cases in whom PEGJ was carried out. 34 patients underwent the Ponsky-Gauderer technique, 6 patients underwent the Sacks-Vine technique, and 2 patients underwent a PEGJ. 24 hours after the PEGJ enteral nutrition (EN) was begun in a progressive manner. During the hospitalization period there was a daily follow up of the patient. In those cases in which At Home Enteral Nutrition was programmed, the patients/families were trained in the techniques and the care of the PEG and the EN, and the control was carried out through the Nutrition out patient department.

RESULTS

PEG was successfully carried out in 42 patients (88%). 35 patients had previously been given EN through a naso-gastric tube (NGT), while in 7 cases the PEG was the first enteral access route. The average duration of the PEG was 212 days, and 27 patients (64%) needed the PEG for more than 3 months. The mean caloric supply was 1921 +/- 200 kcal/day. The mode of administration was by means of an intermittent infusion by gravity in 31 cases, and by continuous infusion using a volumetric pump in 11 patients. Two patients with pregnancy induced hyperemesis underwent a PEGJ in the 3rd and the 4th month of pregnancy, with the pregnancy being successfully brought to term and ending in vaginal deliveries. Carrying out a PEG permitted release from hospital and the programming of At Home Enteral Nutrition in 30 patients. With respect to the evolution of the patients, 22 patients have died during the course of the study. 18 patients remain in follow up in an ambulatory Enteral Nutrition program, and in the two patients with pregnancy induced hyperemesis, the PEGJ was removed after the pregnancy was successfully ended. There were no complications of any kind in 21 patients. The most common complication was the infection of the gastrostomy, which occurred in 13 patients. There was an accidental removal of the gastrostomy tube in 3 patients. In 3 cases there was an eversion of the gastric mucosa through the ostomy within the first 24-hours, and 20 days after the PEG respectively. In 2 cases there was an incarceration of the gastrostomy tube in the abdominal wall. Only two patients showed an important reflux of the gastric contents. There were no deaths as a result of PEG complications.

CONCLUSION

From our experience we can conclude the advantages of PEG as a long term nutritional support, showing a low incidence of complications, and the endoscopic technique has a zero mortality.

Esophageal obstruction by solidification of the enteral feed: a complication to be prevented

We report three cases of esophageal obstruction due to solidification of enteral feed refluxed from the stomach in patients being fed through a nasogastric tube. All three patients were administered sucralfate continuously by tube. The few previous descriptions of this rare complication have also implicated sucralfate with its pathogenesis. Given its clinical importance and the growing use of long-term enteral nutrition, this adverse event needs to be considered.

[Evaluation of energy metabolism in burn patients: indirect calorimetry predictive equations]

INTRODUCTION

Knowing the most reliable method for measuring the metabolic energy use (MEU), is of great importance in patients with severe burns. For the calculation of the energetic requirements of large burn patients, several predictive equations (PE's) are used, based on weight, size, age, body surface area (BSA), and burned body surface (BBS). Previous studies note the tendency for over-or underestimating the MEU, depending on whether one or another PE is used, which is why it is considered necessary to calculate the energy requirements in the most exact manner possible, which can be done by means of indirect calorimetry (IC).

MATERIAL AND METHODS

18 patients (14 men and 4 women) who were admitted to the Burn Unit between 1994 and 1995, were included in the study, with the following inclusion criteria; age > 18 years and < 65 years, and who presented deep burns on are than 15% of the body surface. The MEU of the patients was evaluated by means of IC, using a Deltatrac il unit. The MEU calculated by means of IC was compared with that calculated by means of the four most commonly used PE's in literature: Long Formula: MEU = Basal energy use (BEU) x activity factor x aggression factor which is variable according to the BBS; Curreri Formula: MEU = (Weight x 25) + (total BBS x 40); MEU = 2000 x BSA. As statistical methods, one looked for the existence of correlation, by means of the Pearson method, and the "r" were compared by means of the Fischer conversion. The regression coefficient was found among the values obtained through the PE's and those measured by IC, as well as among those of IC and the percentage of deep burn and the total burned body surface.

RESULTS

All the formulate included overestimated the MEU measured between 30.6% and 43.8% with the 2 x MEU formula being the one which did so least (30.6%). In any of them, there is an important variation of the percentage of overestimation with respect to the average MEU in this group. All are correlated in an important way with the MEU. The reliability of these PE's is variable, as is shown by the slopes of the regression lines, with the most reliable PE being that of 2000 x BSA, and that of 2 x MEU, by Harris-Benedict. There is also correlation between the average MEU by IC and the deeply burned body surface.

CONCLUSION

This study proves the usefulness of the IC for knowing the EME in burn patients, to prevent their hypernutrition, as well as the relative value of the formulae usually used clinically to estimate this parameter.

Correlation of MDR1 expression and oncogenic activation in human epithelial ovarian carcinoma

The expression of the MDR1 gene has been shown to correlate with tumor aggressiveness and oncogenic activation both in experimental tumor models and in human clinical specimens In order to verify whether this association also takes place in ovarian carcinoma, we studied tumor samples from 39 patients by means of immunohistochemistry for the overexpression of P-glycoprotein (MDR1), nm23, c-erb-B2 and p53. MDR1 (p = 0.023), nm 23 (p = 0.037) and c-erb-B2 (p = 0.015) were expressed significantly more in specimens from patients with advanced stage of disease. There were no differences in p53 expression between both groups of patients. Furthermore, we found a significant coexpression of MDR1 and nm23 (p = 0.028), and of MDR1 and c-erb-B2 (p = 0.0077). There was no association between the expression of the MDR1 gene and p53. These results parallel those previously reported by us for mammary carcinoma, and seem to indicate that expression of the multidrug resistance gene (MDR1) is inherent to the development of the malignant phenotype in several human tumors.

S-phase fraction identifies high-risk subgroups among DNA-diploid breast cancers

The prognostic value of DNA content measured by means of flow cytometry was analyzed in formalin-fixed, paraffin-embedded samples from 231 breast cancer patients treated between 1984 and 1988, with a mean follow-up period of 55 months. We followed the guidelines of a Consensus Meeting held on this issue in Maine, USA, in 1992. DNA-diploid and -aneuploid tumors were evaluated separately for the fraction of cells in S-phase (SPF) contained in them, this being divided into three groups ('high', 'intermediate', and 'low'), defined by the 25th and 75th centile of the SPF-distribution corresponding to either DNA-diploid or DNA-aneuploid tumors. Unequivocally readable histograms were obtained from 174 samples (75.3%). A high SPF in diploid tumors was significantly associated with a higher recurrence rate (p = 0.015), a shorter disease-free survival (p = 0.014), advanced (IIIB) clinical stage (p = 0.034), and almost significantly with total survival (p = 0.055). In a multivariate Cox regression analysis, a high SPF in diploid tumors retained its independent prognostic power, being significantly associated with a shorter disease-free survival (p = 0.00049) and total survival (p = 0.0077). It also allowed to identify a subgroup with an ominous prognosis among patients < or = 50 years of age with early stage tumors. Our results fully validate the recommendations of the 1992 Maine Consensus Meeting.

[Decrease of the incidence of sepsis syndrome after early enteral nutrition of patients with severe burns]

The objective of this study was to evaluate the effect of early enteral nutrition on the incidence of the septic syndrome as well as its tolerance, in patients with severe burns. We retrospectively studied 64 patients older than 15 years of age, with a greater than 20% burned body surface area. They were divided into 2 groups as a function of the time elapsed between the beginning of Enteral Nutrition and the time of the burning: 23 patients were given Enteral Nutrition within 24 hours after the burn, and in 41 patients the enteral nutrition was started later than 24 hours after sustaining the thermal injury. Both groups were similar with respect to age, sex, percentage of 2nd and 3rd degree burns, incidence of inhalation, and deaths. All patients received the Enteral Nutrition through a nasogastric tube, with administration of a polymeric, hyperprotein and hypocaloric formula through a continuous infusion pump. In our study we saw a reduction of the incidence of the septic syndrome in the patients who received early enteral Nutrition (26%; 6 patients of a total of 23), with respect to those who did non receive early Enteral Nutrition (54%; 22 patients of a total of 41), with a statistical significance of p > 0.05. There were no differences between both groups with respect to the digestive tolerance to Enteral Nutrition. From our study we can deduce that early Enteral Nutrition reduces the incidence of septic complications, without this increasing the digestive intolerance to the same.

Chemotherapy-induced emesis: management of early and delayed emesis in milder emetogenic regimens

The objective of the present study was to examine the problem of the control of nausea and vomiting induced by non-cisplatin containing cyclophosphamide-based chemotherapy regimens in breast cancer patients. This was randomized, double-blind, parallel-group and placebo-controlled study comparing the efficacy of three antiemetic therapeutic regimens (ondansetron for 3 days, ondasetron plus metoclopramide, and ondansetron given in a single dose) in breast cancer patients receiving cyclophosphamide-based chemotherapy regimens on an outpatient basis. Both the primary and the secondary efficacy were measured. The primary efficacy variable was the number of emetic episodes (considering early and delayed emesis). The secondary efficacy variable measured was the quality of life. Two-by-two tables using the chi-square test and relative-risk concept were elaborated for statistical analysis. There was no difference between high-dose ondansetron and ondansetron plus metoclopramide among patients given CMF (cyclophosphamide, methotrexate, 5-fluorouracil). The single-dose ondansetron regimen showed the worst results. In patients given an FEC regimen (cyclophosphamide, epirubicin, 5-fluorouracil) the antiemetic efficacy was best for the high-dose ondansetron regimen, followed by the ondansetron plus metoclopramide regimen, and was worst for single-dose ondansetron administration. Despite the use of different antiemetic schedules, nausea and emesis are significant problems in patients receiving cyclophosphamide-based chemotherapy. Their adequate control should be the aim of any antiemetic approach.

nm23 expression in advanced and borderline ovarian carcinoma

Twenty-four advanced (surgical stage III and IV) ovarian carcinomas and 15 borderline ovarian tumours were studied for the overexpression of nm23 and HER-2/neu (c-erb-B2) by means of immunohistochemistry on sections from routinely processed, paraffin-embedded, archival tumour blocks, using the NCL-nm23 and the NCL-CB11 monoclonal antibodies and the streptavidin-biotin-peroxidase technique. Significantly more advanced ovarian carcinomas (p = 0.034) expressed high levels of nm23 when compared to borderline tumours. HER-2/neu (c-erb-B2) expression, as could be expected, was also significantly more frequent in advanced ovarian carcinomas (p = 0.006). We were not able to find the previously reported association between nm23 and HER-2/neu overexpression in our tumours. Our results on nm23 overexpression in ovarian cancer are coincident with those previously reported using nm23-mRNA measurements on fresh ovarian tissues. Thus, ovarian carcinoma seems to belong to the group of tumours, like colon carcinoma and neuroblastoma, in which nm23 overexpression is associated with a more malignant phenotype. Immunohistochemistry performed on archival samples from ovarian carcinomas seems adequate for the demonstration of nm23 overexpression in ovarian cancer. This opens the possibility for larger studies on series of patients with a closed follow-up, which could help to establish the role of this gene in this kind of tumour.

[Analysis of preoperative reserve criteria and intraoperative transfusion of blood derivatives at an anesthesiology and recovery service]

Three hundred and three patients undergoing elective surgery were studied prospectively. Patient data and results of serial blood cell counts were recorded before and after surgery and used to evaluate the criteria used to reserve and transfuse blood and blood products, as well as to assess the outcome of transfusions performed. Six hundred and ninety-nine units were reserved, indicating a reservation-to-transfusion ratio of 1.8. The most often cited reasons for reserving blood were surgical technique, nature of disease and prolonged surgery. A high number of reservations were called for from the ward by the surgeons themselves. A total of 180 patients were given transfusions, the main reason being the anesthesiologist's judgement that the Hb count was low (in 26% of cases). Transfusions because of slight bleeding during surgery and prolonged surgery gave rise to the highest Hb counts. The lowest post-transfusion Hb counts recorded occurred when the reason cited was presence of signs of anemia. We conclude that the ratio of reservations to transfusions in our study was acceptable, as were the reasons justifying reserves. There is an overall tendency to achieve excessively high Hb counts (10-11 g/dl) in the early postoperative period. The best criterion for performing transfusion is the presence of signs of anemia.

Correlation of P-glycoprotein overexpression and cellular prognostic factors in formalin-fixed, paraffin-embedded tumor samples from breast cancer patients

BACKGROUND

P-glycoprotein overexpression seems to play a prognostic role independent from its association with multidrug resistance. We have been able to verify this previously on fresh-frozen tumor samples, but up to now P-glycoprotein detection on formalin-fixed, paraffin-embedded material has generally been unsatisfactory.

METHODS

Two distinct groups of previously untreated mammary carcinomas were studied for P-glycoprotein expression by means of immunohistochemistry, using the NCL-p-GLYp polyclonal antibody, carried out on slides from archival, paraffin-embedded material. The first group was composed of 15 tumors expressing at least three out of four factors indicative of a worse prognosis: c-erb-B2, mutant p53, cathepsin-D and PCNA (proliferating cell nuclear antigen). The control group was composed of 16 tumors lacking expression of any of these proteins.

RESULTS

There was a statistically significant difference in survival (Fisher's exact test, p = 0.0036) between both groups. All four patients who died during the follow-up period (mean 55.1 months) belonged to the first group. Three of these patients harbored tumors with the highest level of expression of P-glycoprotein. This association between P-glycoprotein overexpression and prognosis was also statistically significant (Fisher's exact test, p = 0.0059).

CONCLUSION

These results, obtained from a group of mostly operable tumors stratified for cellular risk factors, complement those previously reported by us for locally advanced, inoperable breast cancer only, using fresh-frozen tissue. P-glycoprotein again seems to play a prognostic role, independent of its involvement in multidrug-resistance. The technique used by us yielded useful results on formalin-fixed, paraffin-embedded archival tumor samples. This opens the possibility for larger studies on populations with a closed follow-up.

Dietary treatment of lymphedema by restriction of long-chain triglycerides

Two patients suffering from idiopathic unilateral lower limb lymphedema were treated with a diet in which long-chain triglycerides (LCT) were drastically restricted. From the beginning of the treatment, a distinct improvement was observed in both patients, with reduction of the affected limb perimeters, decrease of edema tension, and decrease of skin turgescence. Patient A underwent weight loss, and the reduction of the diameter of the affected limb was greater than that in the nonaffected limb. In patient B, whose weight remained stable during the study, the diameter of the affected limb underwent a remarkable diminution, while no changes were detected in the nonaffected limb. To the authors' knowledge, this is the first report of dietary treatment of idiopathic lymphedema, these being preliminary results of an ongoing study in a group of patients suffering from lymphedema treated with a low LCT diet.