Mortality as a Function of Survival

Everyone has a chronological age. Because survivorship declines relentlessly in populations with age-specific death rates greater than zero, everyone also has a survivorship age ("s-age"), the age at which a proportion s of the population is still alive. S-ages can be estimated for both periods and cohorts. While trajectories of mortality over chronological ages differ (e.g., across populations, over time, by sex, or by any subpopulation), mortality trajectories over s-ages are similar, a sign that populations experience similar mortality dynamics at specific levels of survivorship. We show that this important demographic regularity holds for 23 sex-specific populations analyzed during a period comprising more than 100 years.

Regularities in human mortality after age 105

Empirical research on human mortality and extreme longevity suggests that the risk of death among the oldest-old ceases to increase and levels off at age 110. The universality of this finding remains in dispute because of two main reasons: i) high uncertainty around statistical estimates generated from scarce data, and ii) the lack of country-specific comparisons. In this article, we estimate age patterns of mortality above age 105 using data from the International Database on Longevity, an exceptionally large and recently updated database comprising more than 13,000 validated records of long-lived individuals from eight populations. We show that, in all of them, similar mortality trajectories arise, suggesting that the risk of dying levels off after age 105. As more high-quality data become available, there is more evidence in support of a levelling-off of the risk of dying as a regularity of longevous populations.

Stratification in health and survival after age 100: evidence from Danish centenarians

BACKGROUND

The existence of a super-select group of centenarians that demonstrates increased survivorship has been hypothesized. However, it is unknown if this super-select group possesses similar characteristics apart from extreme longevity.

METHODS

In this study, we analyse high-quality health and survival data of Danish centenarians born in 1895, 1905 and 1910. We use Latent Class Analysis to identify unobserved health classes and to test whether these super-select lives share similar health characteristics.

RESULTS

We find that, even after age 100, a clear and distinct gradient in health exists and that this gradient is remarkably similar across different birth cohorts of centenarians. Based on the level of health, we identify three clusters of centenarians - robust, frail and intermediate - and show that these groups have different survival prospects. The most distinctive characteristic of the robust centenarians is the outperformance in different health dimensions (physical, functional and cognitive). Finally, we show that our health class categorizations are good predictors of the survival prospects of centenarians.

CONCLUSIONS

There is a clear stratification in health and functioning among those over 100 years of age and these differences are associated with survival beyond age 100.

Progression of the smoking epidemic in high-income regions and its effects on male-female survival differences: a cohort-by-age analysis of 17 countries

BACKGROUND

Of all lifestyle behaviours, smoking caused the most deaths in the last century. Because of the time lag between the act of smoking and dying from smoking, and because males generally take up smoking before females do, male and female smoking epidemiology often follows a typical double wave pattern dubbed the 'smoking epidemic'. How are male and female deaths from this epidemic differentially progressing in high-income regions on a cohort-by-age basis? How have they affected male-female survival differences?

METHODS

We used data for the period 1950-2015 from the WHO Mortality Database and the Human Mortality Database on three geographic regions that have progressed most into the smoking epidemic: high-income North America, high-income Europe and high-income Oceania. We examined changes in smoking-attributable mortality fractions as estimated by the Preston-Glei-Wilmoth method by age (ages 50-85) across birth cohorts 1870-1965. We used these to trace sex differences with and without smoking-attributable mortality in period life expectancy between ages 50 and 85.

RESULTS

In all three high-income regions, smoking explained up to 50% of sex differences in period life expectancy between ages 50 and 85 over the study period. These sex differences have declined since at least 1980, driven by smoking-attributable mortality, which tended to decline in males and increase in females overall. Thus, there was a convergence between sexes across recent cohorts. While smoking-attributable mortality was still increasing for older female cohorts, it was declining for females in the more recent cohorts in the US and Europe, as well as for males in all three regions.

CONCLUSIONS

The smoking epidemic contributed substantially to the male-female survival gap and to the recent narrowing of that gap in high-income North America, high-income Europe and high-income Oceania. The precipitous decline in smoking-attributable mortality in recent cohorts bodes somewhat hopeful. Yet, smoking-attributable mortality remains high, and therefore cause for concern.

Latin American convergence and divergence towards the mortality profiles of developed countries

It is uncertain whether Latin America and Caribbean (LAC) countries are approaching a single mortality regime. Over the last three decades, LAC has experienced major public health interventions and the highest number of homicides in the world. However, these interventions and homicide rates are not evenly shared across countries. This study documents trends in life expectancy and lifespan variability for 20 LAC countries, 2000-14. By extending a previous method, we decompose differences in lifespan variability between LAC and a developed world benchmark into cause-specific effects. For both sexes, dispersion of amenable diseases through the age span makes the largest contribution to the gap between LAC and the benchmark. Additionally, for males, the concentration of homicides, accidents, and suicides in mid-life further impedes mortality convergence. Great disparity exists in the region: while some countries are rapidly approaching the developed regime, others remain far behind and suffer a clear disadvantage in population health.

The effect of a single, large bolus of vitamin D in healthy adults over the winter and following year: a randomized, double-blind, placebo-controlled trial

BACKGROUND/OBJECTIVES

Although single, high doses of vitamin D effectively maintain vitamin D sufficiency in several populations, no studies have evaluated healthy adults over winter, during which vitamin D status declines. This study investigated whether high-dose vitamin D3 given once to healthy adults before winter will (1) prevent the wintertime decline in vitamin D status, (2) promote vitamin D sufficiency 1 year following the dose and (3) prevent the rise of parathyroid hormone (PTH) concentrations.

SUBJECTS/METHODS

In this double-blind, placebo-controlled trial, we assessed plasma 25(OH)D and PTH concentrations at baseline, 5, 90 and 365 days after drug administration in 28 healthy adults. In all, >80% of subjects returned at each time point.

RESULTS

At baseline, the young, healthy participants had a mean plasma 25(OH)D concentration of 17.5±6.1 ng/ml. Only two subjects exhibited plasma 25(OH)D concentrations >30 ng/ml. At 5 days, subjects randomized to vitamin D3 had a higher mean plasma 25(OH)D concentration compared with the placebo group (39.1 vs 19.1 ng/ml, P<0.001). Plasma 25(OH)D concentrations returned to baseline at 90 and 365 days in the vitamin D3 group and remained unchanged in the placebo group. PTH and calcium concentrations were unrelated to changes in 25(OH)D levels and similar between groups over time.

CONCLUSIONS

A dose of 250,000 IU of vitamin D3 given once in November resulted in a robust increase in plasma 25(OH)D after 5 days, but it was unable to sustain this increase after 90 days. A larger or more frequent dosing regimen may be needed for long-term vitamin D sufficiency.

Foundry sands as low-cost adsorbent material for Cr (VI) removal

The potential of foundry sands, industrial waste from the iron foundry industry, was evaluated for the removal of Cr (VI) using discontinuous assays. Chemical foundry sands are composed of fine silica sand, furanic resins as binder, chemical catalyst and residual iron particles. The influence ofpH, agitation rate and metal concentration on the removal process was investigated. Kinetic and equilibrium tests were conducted to determine Cr (VI) removal from aqueous solutions at a temperature range of 25-55 degrees C. Cr (VI) removal of 40-100% for a range of pH 6-1.6 was obtained. This removal was attributed to the presence of a large number of protonated silanol and aluminol groups. Cr (VI) adsorption in foundry sands follows a pseudo-second-order kinetic reaction (Ho model, r2 > 0.999) reaching kinetic constants of 0.341, 0.551, 0.775 and 0.920 g/mg h at 25, 35, 45 and 55 degrees C, respectively. The adsorption data were fitted to the Langmuir adsorption isotherm model (r > 0.99) obtaining adsorption capacities (q(max)) of 1.99, 2.40, 2.50, and 3.14 mg Cr (VI)/g sand at 25, 35, 45 and 55 degrees C, respectively. Calculated Gibbs free energy change (deltaG0), adsorption energy (E) and activation energy (E(a)) values indicate that a physisorption mechanism governs Cr (VI) adsorption process in foundry sands.

Surgical repair and biological therapy for fecal incontinence in Crohn's disease involving both sphincter defects and complex fistulas

BACKGROUND AND AIMS

Surgeons have traditionally tried to avoid any complex surgical procedures in Crohn's patients with complex perianal diseases because of the fear of complications, worsening the patient's condition and risking an eventual proctectomy. The introduction of biological therapy has changed the management of Crohn's disease. This study assesses the long-term success of addressing defects in anal sphincter and complex fistula when patients receive anti-TNF-α antibodies.

METHODS

Ten consecutive patients were prospectively scheduled for induction therapy with 5mg/kg Infliximab at week 0, 2 and 6 and maintenance every 8 weeks associated with azathioprine. Elective surgery was performed conducting a simultaneous approach to the sphincter defect and fistula tracts. Outcomes were long-term continence, complications which were assessed by a Wexner's score along with a complementary questionnaire. Statistical analysis was performed using general linear model of repeated measures.

RESULTS

Three patients had complications related to surgery: two abscesses and low intersphincteric fistula and one case of rectal stenosis causing fecal urgency. There was no suture dehiscence. Wexner's score improved at 12 months (10.0±2.4 vs. 18.0±2.6; p=0.003) and over time (48 month 9.5±2.8; p=0.001). These scores were significantly worse when patients had urgency before treatment (12.8±1.2 vs. 9.5±2.8; p=0.03) but not when the urgency appeared later. No patient remained incontinent to solid stools. Three patients had occasional incontinence to liquid stools associated to disease reactivation.

CONCLUSION

Surgical repair and immunomodulator therapy with infliximab could be an option in incontinent patients with Crohn's disease involving both a sphincter defect and severe or refractory fistulas.

The effect and fate of antibiotics during the anaerobic digestion of pig manure

This work studies the inhibitory effects and fate of the antibiotics oxytetracycline (OTC) and chlortetracycline (CTC) during the anaerobic digestion of pig manure. Both substances were added together in batch assays at concentrations of 10, 50 and 100mgL(-1). Control assays only with antibiotics (abiotic) as well as without antibiotics (biotic) were also conducted. Methane production was reduced by 56%, 60% and 62% at OTC and CTC concentrations of 10, 50 and 100mgL(-1), respectively. The IC(50) level calculated from these experiments was estimated to be around 9mgL(-1), a significant value considering the reported concentrations of these compounds in pig manure samples (up to 136mgL(-1)). Strong adsorption to solid matter was observed, which increased the stability of both substances. Antibiotic degradation was thus much higher in control assays, without solids, than those determined from assays including inoculum and manure substrate.

[Epidural anesthesia for cesarean section in a patient with von Hippel-Lindau disease]

Von Hippel-Lindau disease is a dominant autosomal genetic condition with variable penetrance and expressivity. It is characterized by hemangioblastomas in multiple organs but mainly in the retina and cerebellum. There is a predisposition to carcinoma. We report a cesarean section in a 28-year-old woman with von Hippel-Lindau disease. She had no neurologic symptoms at the time of the operation but a history of ocular and cerebellar involvement and several procedures to remove cerebellar hemangioblastomas. Epidural anesthesia was chosen given that there was no nervous system involvement at the time of surgery.

A methodology for optimising feed composition for anaerobic co-digestion of agro-industrial wastes

An optimisation protocol for maximising methane production by anaerobic co-digestion of several wastes was carried out. A linear programming method was utilised to set up different blends aimed at maximising the total substrate biodegradation potential (L CH(4)/kg substrate) or the biokinetic potential (L CH(4)/kg substrate d). In order to validate the process, three agro-industrial wastes were considered: pig manure, tuna fish waste and biodiesel waste, and the results obtained were validated by experimental studies in discontinuous assays. The highest biodegradation potential (321 L CH(4)/kg COD) was reached with a mixture composed of 84% pig manure, 5% fish waste and 11% biodiesel waste, while the highest methane production rate (16.4 L CH(4)/kg COD d) was obtained by a mixture containing 88% pig manure, 4% fish waste and 8% biodiesel waste. Linear programming was proved to be a powerful, useful and easy-to-use tool to estimate methane production in co-digestion units where different substrates can be fed.

Joint Practice Guidelines for Radionuclide Lymphoscintigraphy for Sentinel Node Localization in Oral/Oropharyngeal Squamous Cell Carcinoma

Involvement of the cervical lymph nodes is the most important prognostic factor for patients with oral/oropharyngeal squamous cell carcinoma (OSCC), and the decision of whether to electively treat patients with clinically negative necks remains a controversial topic. Sentinel node biopsy (SNB) provides a minimally invasive method for determining the disease status of the cervical node basin, without the need for a formal neck dissection. This technique potentially improves the accuracy of histologic nodal staging and avoids overtreating three-quarters of this patient population, minimizing associated morbidity. The technique has been validated for patients with OSCC, and larger-scale studies are in progress to determine its exact role in the management of this patient population. This document is designed to outline the current best practice guidelines for the provision of SNB in patients with early-stage OSCC, and to provide a framework for the currently evolving recommendations for its use. Preparation of this guideline was carried out by a multidisciplinary surgical/nuclear medicine/pathology expert panel under the joint auspices of the European Association of Nuclear Medicine (EANM) Oncology Committee and the Sentinel European Node Trial (SENT) Committee.

[Maternally Inherited Diabetes and Deafness]

CASE REPORT

We described the follow up of a patient with diabetes mellitus type 2 who had a macular pattern dystrophy and bilateral neurosensory hearing loss. Electrophysiological studies revealed abnormal pattern electroretinography and impaired electro-oculogram responses.

DISCUSSION

Maternally Inherited Diabetes, neurosensory Deafness and generally macular pattern distrophy (MIDD syndrome), is a rare mitochondrial disease, responsible for approximately 0.5 to 2.8% of diabetes mellitus.

Municipal wastewater treatment in an anaerobic digester-constructed wetland system

An experimental plant was constituted for an upflow anaerobic sludge blanket (UASB) reactor with an active volume of 25.5 m3 and two horizontal constructed wetlands of 75 m2 each. The first wetland was a superficial flow (SF) system and the second a subsurface flow (SSF) system. The UASB reactor was fed with 60-73 m3 d(-1) of raw domestic wastewater from the municipal treatment plant (MTP) of the city of Santiago de Compostela. Part of the effluent from the UASB reactor (15 m3 d(-1)) passed through the SF wetland and then went into the SSF. In the first ten months of operation, from July 2005 to April 2006, the hydraulic retention time for the UASB system was in the range of 7-14 hours and the organic loading rate (OLR) was between 0.3 and 1.1 g COD l(-1) d(-1). The organic load in the wetlands was in the range of 5-40 g BOD5 m(-2) d(-1). The global results achieved for total suspended solids (TSS), chemical oxygen demand (COD) and biological oxygen demand (BOD5) removal efficiencies were 85-96%, 65-90% and 69-93%, respectively. The average monthly concentrations in the final effluent were 8-73 mg BOD5 l(-1), 25-120 mg COD l(-1) and 6-20 mg TSS l(-1). The global balance of VSS in the UASB reactor shows that purge accounted for 19.6% and hydrolysis accounted for 47.7% of influent VSS. Data from suspended solids balance in the constructed wetlands, at the end of the operation period, show a TSS and VSS accumulation of 48% and 16%, respectively.

Anaerobic treatment of low-strength municipal wastewater by a two-stage pilot plant under psychrophilic conditions

A two-stage anaerobic treatment pilot plant was tested for the treatment of raw domestic wastewater under temperatures ranging from 21 to 14 degrees C. The plant consisted of a hydrolytic upflow sludge bed (HUSB) digester (25.5m3) followed by an upflow anaerobic sludge blanket (UASB) digester (20.36m3). The hydraulic retention time (HRT) varied from 5.7 to 2.8h for the first stage (HUSB digester) and from 13.9 to 6.5h for the second stage (UASB digester). Total suspended solids (TSS), total chemical oxygen demand (TCOD), and biochemical oxygen demand (BOD) removals ranged from 76% to 89%, from 49% to 65%, and from 50% to 77%, respectively, for the overall system. The percentage of influent COD converted to methane was 36.1%, the hydrolysis of influent volatile suspended solids (VSS) reached 59.7% and excess biomass was 21.6% of the incoming VSS. Plant performance was influenced by the wastewater concentration and temperature, yet better results were obtained for influent COD higher than 250mg/l.

Start-up alternatives and performance of an UASB pilot plant treating diluted municipal wastewater at low temperature

Different start-up procedures of an upflow anaerobic sludge bed (UASB) digester were carried out. Start-up without inoculum (experiment A) was delayed for about 120 day. The digester reached 75-85% total suspended solids (TSS) removal, 54-58% total chemical oxygen demand (TCOD) removal and 63-73% biological oxygen demand (BOD5) removal at influent concentrations of 240-340 mg TCODil-1, temperatures of 13.5-15 degrees C and hydraulic retention times (HRT) of 10-11 h. Digested sludge was used as inoculum in experiment B. After the start-up period of 75 days, digester efficiencies were 58%, 41% and 54% for TSS, TCOD and BOD5 removal, respectively, working at 169 mg TCODil-1, temperature of 14 degrees C and HRT of 11 h. The sludge bed developed and stabilised quickly when using a hydraulically adapted inoculum (experiment C), but TCOD and BOD5 removals remained low and volatile fatty acids (VFA) accumulated in the effluent.

Nonimmediate reactions to systemic corticosteroids suggest an immunological mechanism

BACKGROUND

Administration of corticosteroids (CS) by different routes may cause varying types of allergic reactions, thereby hampering their further use in affected patients. In order to verify an immunological involvement we evaluated a group of patients with symptoms compatible with nonimmediate allergic reactions to CS.

METHODS

Studies included patch and intradermal tests, immunohistochemical studies and controlled administration to reproduce the response. The cytokines interleukin (IL)-4, interferon (IFN)-gamma and tumor necrosis factor (TNF)-alpha were quantified in peripheral blood during the response.

RESULTS

Of 32 subjects evaluated presenting nonimmediate urticaria or exanthema, 21 were finally considered positive after re-exposure. The drugs most frequently involved were betamethasone and dexamethasone. Fewer than half the patients responded to prednisolone whilst some responded to three or more CS. Hydrocortisone and deflazacort were well tolerated by all the patients. Subjects with a positive intradermal or patch test had a perivascular mononuclear cell infiltrate with the presence of CD4 and CD8 lymphocytes positive for CD45RO+ (memory) and CD69 (activation marker) cells. Monitoring peripheral blood during the acute response showed expression of IFN-gamma and TNF-alpha, with downregulation of IL-4.

CONCLUSION

Adverse systemic responses to different CS are suggestive of a nonimmediate reaction. The symptoms elicited together with the immunlogical studies suggest a T-cell mediated response. The response to closely related CS was especially marked between betamethasone and dexamethasone, whereas hydrocortisone and deflazacort were well tolerated.

Performance of a UASB-digester system treating domestic wastewater

The anaerobic treatment of raw domestic wastewater by a novel technology consisting of an Up-flow Anaerobic Sludge Bed (UASB) reactor combined with a completely mixed digester for the stabilisation of the UASB sludge was assessed. A pilot-scale plant of the so-called UASB-Digester system was located at the municipal wastewater treatment facility of Santiago de Compostela (Northwest of Spain). The main aim of the Digester was to enhance the biodegradation of influent solids retained in the UASB reactor at low temperatures, then increasing its specific methanogenic activity. The sludge drawn from the middle zone of the UASB entered the upper zone of the Digester and then circulated from the bottom of the Digester to the UASB bottom. Circulating in an automated semi-continuous way, the flow of this sludge stream was selected in order to set a previously defined hydraulic retention time (HRT) (16-27 d) in the digester. The Digester temperature was set at an optimum value ranging from 25 to 35 degrees C. The steady state efficiency of the UASB system, at 6-8 h of HRT, 15-16 degrees C of temperature and 330-360 mg l(-1) of influent total chemical oxygen demand (TCOD) was 79% of total suspended solids (TSS) removal, 52% of TCOD removal and 60% of biological oxygen demand (BOD5) removal. The hydrolysis of retained solids reached 85%, while excess sludge generation was only 7% of influent TCOD. A stable anaerobic (pre)treatment of diluted domestic wastewater was reached as the sludge concentration in the reactor remained mainly constant and the specific methanogenic activity showed a slight increase.

Incarcerated groin hernias in adults: Presentation and outcome

Despite universal acceptance of the value of elective hernia repair, many patients present with incarceration or strangulation, which are associated with significant morbidity and mortality. We reviewed 147 patients who underwent emergency surgery for incarcerated groin hernias during a 10-year period in order to analyze the presentation and outcome in our practice. Median age of the patients was 70 years. There were 77 men and 70 women. Femoral hernias were seen in 77 patients and inguinal hernias in 70. Coexisting diseases were found in 82 cases (55.8%). Bowel resection was required in 19 patients (12.9%). The overall and major morbidity rates were 41.5% and 9.6%, respectively. The mortality rate was 3.4%. Longer duration of symptoms, late hospitalization, concomitant diseases, and high ASA class were found to be significant factors linked with unfavorable outcomes. Because of high morbidity and mortality associated with incarceration, elective repair of groin hernias should be done whenever possible.

Anaerobic hydrolysis of a municipal wastewater in a pilot-scale digester

Raw domestic wastewater from the city of Santiago de Compostela (Northwest Spain) was fed into a pilot-scale hydrolytic up flow sludge bed (HUSB) digester with an active volume of 25.5 m3. The total influent chemical oxygen demand (COD) ranged from 360 to 470 mg/l, the influent SS varied from 190 to 370 mg/l, and the temperature was between 17 degrees and 20 degrees C. The organic load rate (OLR) applied increased step by step from 1.2 to 3.9 kgCOD/m3 x d, while the hydraulic retention time (HRT) decreased from 7.1 h to 2.9 h. A high suspended solids (SS) removal of about 82-85% from the influent was reached, most of which (81 to 88%) was eliminated by hydrolysis, while the rest remained in the purge stream. The total COD removal ranged from 46 to 59%. On the other hand, a high acidification of the COD remaining in the effluent was obtained, so the percent COD in the form of volatile fatty acids (VFA(COD)) with respect to total effluent COD was about 43% for the highest HRT applied, and about 27% for the lowest HRT. The soluble to total COD ratio (CODs/CODt) increased from 25-32% for the influent to 71-86% for the effluent. The results obtained confirm the viability and interest of direct anaerobic hydrolytic pre-treatment of domestic wastewater.

Delayed rupture of traumatic intracranial pseudoaneurysm in a child following gunshot wound to the head

BACKGROUND AND OBJECTIVES

Traumatic intracranial aneurysms (TICAs) are highly unstable lesions that may rupture within minutes after formation or remain quiescent for several weeks and manifest with delayed hemorrhage and neurologic deterioration. Mortality following a rupture may be 30% to 40%. Among all cerebral aneurysms, the incidence of TICAs is less than 1%; 20% to 30% of TICAs occur in children.

METHODS AND MATERIALS

A child with a low-caliber craniocerebral gunshot wound deteriorated neurologically 12 days after the initial injury and emergency evacuation of an intracranial hematoma. A new massive left frontal hematoma was discovered, caused by the rupture of an unsuspected left pericallosal artery pseudoaneurysm. The new hematoma was evacuated, and the aneurysm was trapped using microsurgical techniques.

RESULTS AND/OR CONCLUSIONS

A high index of suspicion should be maintained for delayed pseudoaneurysm genesis and rupture. A cerebral arteriogram should be obtained when significant subarachnoid hemorrhage or intraparenchymal hematomas are present, when missiles traverse major arteries, or when the pterional or cranioorbitofacial regions are violated. Treatment should be prompt.

Single and multiple pyogenic liver abscesses: etiology, clinical course, and outcome

BACKGROUND

Pyogenic liver abscesses are uncommon but they still carry a high mortality rate when encountered. This study was undertaken to evaluate the differences in the clinical behaviour of patients with single and multiple abscesses.

METHODS

From January 1985 to December 1997, 133 patients with this disease were treated in the surgical departments of five hospitals, 97 had a single abscess and 36 had multiple abscesses. Clinical features, methods of treatment, and outcome were assessed and compared in both types of abscesses.

RESULTS

A biliary origin from ascending cholangitis was most frequently found in multiple abscesses (p = 0.007). Mean age and duration of symptoms were higher in multiple lesions (p = 0.03 and p = 0.001). High levels of alkaline phosphatase were more frequently seen in multiple abscesses than in solitary ones (p = 0.02). They were both most frequently located on the right side. Antibiotic therapy alone was most frequently used in multiple abscesses (p = 0.01). Mortality rate was also higher in this type of patients (p = 0.01). The abscess-related morbidity rate was higher in multiple lesions as well but the statistical difference was not significant.

CONCLUSIONS

These results suggest that multiple liver abscesses comprise a disease of biliary origin, higher age, longer symptomatic periods, and also higher mortality rate than in single abscess.

Left main crumpling during left anterior descending angioplasty: hitherto unreported location for the "accordion effect"

Vessel wall shortening and deformity due to "arterial telescoping" is a not infrequent reversible phenomenon that occurs during coronary angioplasty and is associated with the advancement of a stiff wire through elongated and tortuous segments, with straightening of the artery and deep guiding catheter introduction beyond the coronary ostium. We present the first described case of the accordion effect involving the left main coronary artery. On detecting arterial crumpling, it is essential to make a differential diagnosis between the accordion syndrome and PTCA potential complications (spasm, thrombosis and dissection), to avoid further therapeutic intervention.

Pyogenic liver abscesses: a comparison of older and younger patients

BACKGROUND

Pyogenic liver abscess is a life-threatening disease. Few studies have specifically explored the way in which the clinical features and management of elderly patients with pyogenic liver abscess differ from those of younger individuals.

METHODS

A retrospective study was undertaken to evaluate whether older patients with pyogenic liver abscess have distinctive presenting features or whether their management and outcome differ from that of younger patients. A total of 133 patients with liver abscess treated in five hospitals during 13 years comprised two groups: 78 patients aged 60 years or above (older group) and 55 patients below age 60 years (younger group). Clinical features, laboratory data, imaging and microbiological findings, management and outcome were determined in each group.

RESULTS

The older group contained more patients with associated diseases (p=0.03), nausea and vomiting at presentation (p=0.02), higher APACHE II (Acute Physiological and Chronic Health Evaluation II scale) score (p<0.001) and blood urea nitrogen (p<0.001) and serum creatinine levels (p=0.002). Multiple abscess (p=0.05) and bilobar (p=0.03) abscess were also commoner in this group. By contrast, in the younger group men predominated (p=0.01), and there was a higher overall complication rate (p=0.05).Time to diagnosis, hospital mortality rate and other variables analysed were similar in both groups.

DISCUSSION

Elderly patients with pyogenic liver abscess have some subtle differences in clinical and laboratory presentation, but these do not appear to delay diagnosis. Active management is tolerated well, with a lower morbidity rate than in younger patients and no difference in the mortality rate.

Pharmacological modification of the serotonergic transmitter system and beta-N-acetylhexosaminidase activity in rats

The enzyme activity and activation energy of plasma beta-N-acetylhexosaminidase (Hex) was determined in rats whose serotonergic system had been pharmacologically altered. In the group of animals treated with 5-hydroxytryptophan, in the different dissected brain regions (brain stem, cortex and hippocampus) significantly higher levels of serotonin and 5-hydroxyindolacetic acid were found, and significantly lower in the group treated with p-chlorophenylalanine, than in the control group. In the total number of animals studied (n = 21), a statistically significant correlation was found between the plasma concentration of 5-hydroxyindolacetic acid and the levels of this metabolite in the different brain regions (p < 0.001). No significant differences were found for the activity of Hex in the plasma, or for its activation energy, which is a marker of its isoenzyme composition, among the three groups of animals. The results obtained using our experimental model in rats do not confirm the hypothesis of other authors who suggest that the Hex responds secondary to increases or decreases of serotonin turnover, and could be a biological test to monitor the serotonin status in psychiatric patients.

[An analysis of transfusion in adult surgery]

PURPOSE

To analyze the transfusion rate of adult transfused patients undergoing standard curative surgery made in operating room (not ambulatory).

PATIENTS AND METHODS

Data from discharge reports of patients having surgery during 1996, codified according to the International Diseases Classification (ICE-9-MC). Age, sex, diagnosis, procedures (including transfusions), were analysed along with the surgical procedures and if the patient was subsequently admitted.

RESULTS

11,673 adult patients had surgery, of whom 890 underwent transfusion (7.6%). The transfusion rate was greater in males, in patients over 60 years old, in patients with several surgical procedures simultaneously, in patients who were subsequently admitted, and in patients with surgery procedures of pancreas, spleen, dorsolumbar column, liver, pharynx, hip and stomach.

CONCLUSIONS

Given the variability in the blood transfusion practices among the hospitals, to know the transfusion rates of each clinic and surgical situation would permit a better planning of: the surgical blood transfusions, the autologous blood transfusion program, the criteria on crossmatching tests, as well as to increase the information to the patient in the surgical Informed Consent.

Anterior cervical discectomy for one- and two-level cervical disc disease: the controversy surrounding the question of whether to fuse, plate, or both

Since the introduction of anterior approaches to the cervical spine for the surgical treatment of degenerative disc disease, controversies have developed regarding the necessity of fusion following anterior cervical discectomy, the use of allografts instead of autologous bone for fusion, and, recently, the employment of anterior cervical plating systems in addition to fusion for uncomplicated disc disease. We reviewed seven clinical papers dealing with these issues; these articles surveyed a total of 1153 patients. Several observations can be made from these reviews. First, there is little or no difference in clinical outcome following single-level anterior discectomy, whether a fusion is performed or not, regardless of whether the operation was for soft discs or osteophytes. Second, most patients who underwent two-level discectomies had outcomes comparable to patients who underwent surgery at one level, regardless of whether they were fused or not. Data from four prospective randomized clinical studies in addition to multiple non-randomized or retrospective studies support these conclusions. Although the incidence of complications such as persistent postoperative posterior cervical and shoulder pain and kyphotic deformities is higher in unfused patients (and is quite significant in some series), the advantages conferred by interbody fusion such as biomechanical stability, decreased incidence of kyphotic deformity, and decreased pain are offset by graft and donor-site morbidity. Specific indications for fusion include multi-level discectomies, significant straightening of the cervical spine, failed prior fusions, and trauma. It has been demonstrated that comparable fusion rates can be achieved with allografts rather than harvested autologous bone. The advantages of autografts over allografts are relatively slight in most patients who undergo anterior fusion for one- or two-level disc disease, although patients with impaired healing, significant osteopenia, or concomitant microvascular disease, such as chronic smokers, may benefit from autologous bone. The use of allografts avoids donor-site morbidity in patients without these problems. Anterior cervical plates are useful for cases of instability requiring fusion (such as trauma); these implants may decrease reoperation rates and the incidence of delayed instability in select cases. However, the cost-effectiveness of their generalized use for uncomplicated cervical disc disease has not been demonstrated. In conclusion, a general statement regarding the optimal surgical treatment for cervical disc herniations using anterior approaches is difficult to make with this limited review. Surgeons' experience and familiarity with a particular approach are probably the most important factors in ensuring successful outcomes.

Bovine babesiosis and anaplasmosis follow-up on cattle relocated in an endemic area for hemoparasitic diseases

A multiplex PCR/DNA probe assay was used to monitor Babesia bovis, B. bigemina and Anaplasma marginale infection in cattle introduced to a Boophilus microplus-infested area in Veracruz, Mexico. Eight intact, 18-month-old, cross-bred beef cattle (four naive, Group A; four Babesia species--premunized, Group B) were immediately exposed to ticks after arrival and were clinically monitored from day 6 to day 98 post-exposure (PE) to ticks. Blood sample analysis for DNA detection by the MPCR/DNA probe assay showed that Group A animals were infected with B. bovis from day 11 up to day 22 PE, requiring treatment on days 17-20. Group B animals were detected positive to B. bovis on days 17-20, did not require treatment and remained persistently infected from days 70 to 84 PE. Treatment of Group A animals delayed the infection with B. bigemina. These animals became positive to the parasite on days 63-77 PE. In contrast, Group B animals (untreated) showed B. bigemina infection on days 21-26 and 63-84 PE. One animal was positive for A. marginale infection on days 63-66 PE, the rest of the animals became so on days 80-98 PE. All infected animals required treatment with oxytetracycline. Monitoring the triple hemoparasite infection with the MPCR/DNA probe assay provided important epidemiological information. Thus, precautionary measures can be established when cattle are moved to a babesiosis/anaplasmosis risk area.

Lumbar spine stenosis: a common cause of back and leg pain

Lumbar spine stenosis most commonly affects the middle-aged and elderly population. Entrapment of the cauda equina roots by hypertrophy of the osseous and soft tissue structures surrounding the lumbar spinal canal is often associated with incapacitating pain in the back and lower extremities, difficulty ambulating, leg paresthesias and weakness and, in severe cases, bowel or bladder disturbances. The characteristic syndrome associated with lumbar stenosis is termed neurogenic intermittent claudication. This condition must be differentiated from true claudication, which is caused by atherosclerosis of the pelvofemoral vessels. Although many conditions may be associated with lumbar canal stenosis, most cases are idiopathic. Imaging of the lumbar spine performed with computed tomography or magnetic resonance imaging often demonstrates narrowing of the lumbar canal with compression of the cauda equina nerve roots by thickened posterior vertebral elements, facet joints, marginal osteophytes or soft tissue structures such as the ligamentum flavum or herniated discs. Treatment for symptomatic lumbar stenosis is usually surgical decompression. Medical treatment alternatives, such as bed rest, pain management and physical therapy, should be reserved for use in debilitated patients or patients whose surgical risk is prohibitive as a result of concomitant medical conditions.

Neonatal applications of neuroendoscopy

Neuroendoscopy is a minimally invasive technique that has revolutionized the management of multiple intracranial conditions. Neuroendoscopic techniques can be safely applied to the newborn in selected circumstances, but the indications, surgical technique, and the potential pitfalls and complications must be completely understood to ensure a successful outcome in these fragile patients.

Use of a duplex PCR/DNA probe assay to monitor Babesia bovis and Babesia bigemina in cattle during a vaccination trial

A Duplex Polymerase Chain Reaction (DPCR)/DNA probe assay was used to detect Babesia bovis and B. bigemina DNA in cattle undergoing immunization trials. Blood samples were collected from 15 non-splenectomized, 1-2 years old bulls, inoculated with 1 x 10(7) each of culture-derived B. bovis- and B. bigemina-infected erythrocytes. 15 bulls inoculated with normal erythrocytes served as a control group. All cattle were field exposed to tick-transmitted Babesia 21 days (20 animals, Group I) and 60 days (10 animals, Group II) post-inoculation (PI). After immunization, the DPCR/DNA probe assay detected B. bigemina and B. bovis parasite DNA in all inoculated animals from days 4 to 14 PI. At challenge, B. bovis DNA was detected in all control animals as early as day 8 (Group I), or day 11 (Group II) post-introduction to a tick-infested area. The immunized bulls showed B. bovis positive PCR/DNA probe signals from day 0 (Group II) and day 8 (group I), up to day 32 post-exposure to ticks. Positive B. bigemina signals were detected from day 0 (Group I) and day 8 (Group II), up to day 36 post-exposure to ticks. During challenge, it was not possible to clearly define whether the PCR/DNA probe signals detected in the blood from immunized cattle were a result of amplified DNA from the culture-derived parasites, from the tick-transmitted parasites, or both.

D-2-hydroxy-4-methylvalerate dehydrogenase from Lactobacillus delbrueckii subsp. bulgaricus. II. Mutagenic analysis of catalytically important residues

Five residues involved in catalysis and coenzyme binding have been identified in D-2-hydroxy-4-methylvalerate dehydrogenase from Lactobacillus delbrueckii subsp. bulgaricus by using biochemical and genetical methods. Enzyme inactivation with diethylpyrocarbonate indicated that a single histidine residue was involved in catalysis. Since H296 is the only conserved histidine in the whole family of NAD-dependent D-2-hydroxyacid dehydrogenases, we constructed the H296Q and H296S mutants and showed that their catalytic efficiencies were reduced 10(5)-fold compared with the wild-type enzyme. This low residual activity was shown to be insensitive to diethylpyrocarbonate. Taken together these data demonstrate that H296 is responsible for proton exchange in the redox reaction. Two acidic residues (D259 and E264) were candidates for maintaining H296 in the protonated state and their roles were examined by mutagenesis. The D259N and E264Q mutant enzymes both showed similar and large reductions in their Kcat/K(m) ratios (200-800-fold, depending on pH), indicating that either D259 or E264 (or both) could partner H296. The conserved R235 residue was a candidate for binding the alpha-carboxyl group of the substrate and it was changed to lysine. The R235K mutant showed a 104-fold reduced Kcat/K(m) due to both an increased K(m) and a reduced Kcat for 2-oxo-4-methylvalerate. Thus R235 plays a role in binding the substrate carboxylate similar to R171 in the L-lactate dehydrogenases. Finally, we constructed the H205Q mutant to test the role of this partially conserved histidine residue (in 10/13 enzymes of the family). This mutant enzyme displayed a 7.7-fold increased Kcat and a doubled catalytic efficiency at pH 5, was as sensitive to diethylpyrocarbonate as the wild-type but showed a sevenfold increased K(m) for NADH and a 100-fold increase in Kd for NADH together with 10-30-fold lower substrate inhibition. The transient kinetic behaviour of the H205Q mutant is as predicted from our previous study on the enzymatic mechanism of D-2-hydroxy-4-methylvalerate dehydrogenase which showed that coenzyme binding is highly pH dependent and indicated that release of the oxidised coenzyme is a significant component of the rate-limiting processes in catalysis at pH 6.5.

D-2-hydroxy-4-methylvalerate dehydrogenase from Lactobacillus delbrueckii subsp. bulgaricus. I. Kinetic mechanism and pH dependence of kinetic parameters, coenzyme binding and substrate inhibition

The steady-state kinetics of D-2-hydroxy-4-methylvalerate dehydrogenase have been studied at pH 8.0 by initial velocity, product inhibition, and dead-end inhibition techniques. The mechanism is rapid-equilibrium ordered in the NAD+ plus D-2-hydroxy-4-methylvalerate direction, and steady-state ordered in the other direction. In both cases coenzyme is the first substrate added and both the E-NADH-D-2-hydroxy-4-methylvalerate and E-NAD+-2-oxo-4-methylvalerate give rise to abortive complexes which cause excess substrate inhibition. Steady-state measurements show that the rate-limiting step in both directions at pH 8.0 is between formation of the enzyme-coenzyme-substrate ternary complex and the release of the first product of the reaction. Transient kinetics combined with primary kinetic deuterium isotope effects show that in the NADH-->NAD+ direction there is a slow, rate-limiting rearrangement of the E-NADH-oxoacid complex while hydride transfer is very fast. The release of NAD+ at pH 8.0 is 200-times faster than Kcat (NADH-->NAD+) whereas the release of NADH is only 5-times faster than Kcat (NAD+-->NADH). The pH dependence of NADH binding depends upon the presence of two ionizable residues with a pKa of about 5.9. The pH dependence of kinetic parameters is explained by a third ionizable residue with pKa values 7.2 (in the E-NADH complex) and < or = 6.4 (in the E-NAD+ complex) which may be the proton donor and acceptor for the chemical reaction. At pH 6.5 the mechanism changes in the NADH-->NAD+ direction to be partly limited by the chemical step with a measured primary kinetic isotope effect of 5.7 and partly by an only slightly faster dissociation of NAD+. In addition the inhibition by excess oxo-4-methylvalerate is more pronounced. The mechanism implies that removing the positive charges created by the two groups which control coenzyme affinity could both enhance the catalytic rate at pH 6.5 and diminish excess substrate inhibition to provide an enzyme better suited to the bulk synthesis of D-2-hydroxyacids.

Primary intrinsic brainstem oligodendroglioma in an adult. Case report and review of the literature

Primary intrinsic oligodendrogliomas of the brainstem are exceedingly unusual. The authors report the case of an intraaxial brainstem oligodendroglioma in an adult. In an extensive review of oligodendrogliomas, only six (0.4%) of 1593 cases recorded could be identified as intrinsic brainstem tumors. Five of these cases were found in children. This report documents a 25-year-old woman with a pontomedullary oligodendroglioma. An analysis of the world literature on this tumor type finds that posterior fossa oligodendrogliomas present at an earlier age and appear to be more aggressive biologically than their supratentorial counterparts. The overall prognosis for patients harboring an intrinsic brainstem oligodendroglioma remains unclear, with significant variability between patients.

Comparative sensitivity of two tests for the diagnosis of multiple hemoparasite infection of cattle

The purpose of this study was to evaluate the efficacy of light microscopy (LM) examination of blood smears and a multiplex polymerase chain reaction (MPCR) assay, in terms of their ability to detect cattle experimentally infected with Babesia bovis, Babesia bigemina, and Anaplasma marginale. Blood samples were collected from 32 intact, 1-2 year old, Holstein bulls, previous to and after simultaneous inoculation of culture-derived or field isolates of B. bovis- and B. bigemina-infected erythrocytes. To establish the triple hemoparasite infection, 16 of the bulls were also inoculated with a calf-derived isolate of A. marginale. The results showed that both tests had 100% specificity. In contrast, the sensitivities of the MPCR assay against the LM test were 93.5% and 70.9%; 96.7% and 100%; and 93.8% and 93.8% for B. bovis, B. bigemina, and A. marginale infection, respectively. The advantages and disadvantages of the MPCR assay to differentially diagnose cattle with multiple hemoparasite infection are discussed.

Measurement of the concentrations of solutions through chromatic systems

After a careful check of the response linearity of the spectrophotometer in absorbances and transmittances at wavelengths between 250 and 550 nm with potassium dichromate, the influence of the concentration of solutions on the tristimulus coordinates and the coordinates of the CIE 1931 (Commission Internationale de l'Éclairage) and CIELAB colorimetric systems was analyzed. How to use the value of only some chromatic coordinates to obtain a sample's concentration simultaneously is also shown.

Sensitivity of monoclonal antibodies to carcinoembryonic antigen, tissue polypeptide antigen, alpha-fetoprotein, carbohydrate antigen 50, and carbohydrate antigen 19-9 in the diagnosis of colorectal adenocarcinoma

PURPOSE

This study was designed to establish the sensitivity of monoclonal antibodies to carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), tissue polypeptide antigen (TPA), carbohydrate antigen 50 (CA 50), and carbohydrate antigen 19-9 (CA 19-9) and the efficacy of the joint determination of several tumor markers, as well as the dynamics of postoperative normalization of each marker in the absence of recurrence.

MATERIALS AND METHODS

A prospective study was carried out in 100 patients subjected to surgical resection of colon adenocarcinoma. Serum concentrations of these markers were determined the day before surgery and seven days, two months, and six months after surgery.

RESULTS

The results demonstrate that sensitivity increased as the disease spread and that CA 19-9 was the most sensitive tumor marker. The rate of false negatives was 40 percent for Dukes Stage A lesions, 19 percent for Dukes Stage B, 7 percent for Dukes Stage C, and 0 percent for Dukes Stage D. Determination of two markers (CA 19-9 and CEA) provided the greatest sensitivity in Stages A and D tumors (60 percent and 100 percent, respectively); the incidence did not change when measurements of other antigens were associated. For Stages B and C, determination of at least three markers was necessary, the association of CEA, TPA, and CA 19-9 being that which showed the greatest sensitivity, 78 percent and 91 percent, respectively.

CONCLUSIONS

It would be advisable to include monoclonal antibody determination of CEA, TPA, and CA 19-9 in the diagnosis of adenocarcinoma, despite the fact that ultimate sensitivity will depend on the degree of tumor extension or on the presence of metastasis.

[Carcinosarcoma of the gallbladder]

The authors present a case of carcinosarcoma of the gallbladder, discussing its possible histological origin, clinical picture, and recommended therapeutic approaches. Only 30 cases have so far been reported. The case described was seen because of a painless large volume mass in the right hypochondrium. She was surgically treated with a complete resection of the gross tumor including a portion of choledochus, followed by chemotherapy. The survival was of 20 months.

[Syndromes of continuous muscular activity: report of a central case (stiff-man) and a peripheral case (neuromyotonia) associated with neuroborreliosis]

We describe two cases of continuous muscular activity: one which is central (the stiff-man syndrome), and another which is peripheral (neuromiotony), the latter in a patient suffering from diabetic neuropathy and with positive Borrellia burgdorferi serology in the bloodstream, as well as CSF. Both cases reacted favourably to medical treatment. In the first case botulinic toxin was used as a simultaneous treatment for focal pseudodystonia in one foot. Response was good.

Antibody response to Babesia bigemina infection in calves measured by ELISA and immunoblotting techniques

To measure the antibody response to Babesia bigemina with an ELISA test, three groups of cattle were experimentally infected with two isolates of the parasite. It was possible to demonstrate specific antibody binding directed against the parasite as early as the 7 days postinfection (PI). The highest level of antibody was obtained around day 1 to 23 and remained detectable for 260 days. Challenge of the animals 260 days PI with a tick-induced B. bigemina infection depicted that homologous strain-challenged calves did not show an increase of IgG antibody levels, where as those challenged with the heterologous isolate did. In the latter groups the resulting level of antibodies was even higher than after the primary infection. The immunoblotting technique showed that the antibody response is probably directed against groups of B. bigemina components with a relative mobilities of 68-64 kDa, 62-54 kDa and 52-42 kDa, which appear to be major components of the protozoa. By observing the cross-reacting antigenicity among seven B. bigemina isolates, it was demonstrated that these components are not isolate-restricted.

Localization of basic fibroblast growth factor and vascular endothelial growth factor in human glial neoplasms

Fibroblast growth factors (FGFs) are widely recognized as a family of molecules that can influence cell proliferation and tissue neovascularization. Although the basic form of FGF (bFGF) has been found to enhance the growth of primary cell cultures made from human glial tumors, its exact role in vivo has been unclear. Likewise, vascular endothelial growth factor (VEGF) is a newly discovered addition to the growing list of angiogenic factors but, unlike bFGF, VEGF has a unique specificity for endothelial cells and possesses the properties required for secretion. In this study, we localized both basic FGF and VEGF in human gliomas to assess their possible role in the pathogenesis of these neoplasms. Retrospective analysis was performed using glial neoplasms that were fixed in 10% neutral buffered formalin and embedded in paraffin. The immunocytochemical procedures were performed using specific polyclonal antibodies raised against the amino terminus of bFGF and VEGF, respectively. Immunoreactive (IR) basic FGF was localized in normal, reactive, and neoplastic astrocytes as well as selected populations of normal neurons. IR VEGF, in contrast, was present primarily in neurons of normal brain, but was also found in both reactive and neoplastic astrocytes. In adjacent 4-microns tissue sections, strong immunoreactivity for VEGF and bFGF was found within the same populations of cells. In areas of endothelial proliferation, the strongest immunoreactivity for both growth factors was found within large anaplastic astrocytes that surrounded abnormal blood vessels. Our data support the hypothesis that VEGF may complement the actions of basic FGF in glial neoplasia.

Evaluation of a colorimetric Babesia bigemina-DNA probe within an epidemiological survey

An epidemiological survey was conducted in southeast Mexico, in an effort to establish the serological reactivity and carrier status to Babesia bigemina of an indigenous cattle population. The prevalence was obtained through the Indirect Fluorescent Antibody Test (IFAT), using an in vitro culture-derived B. bigemina antigen. A specific, digoxigenin-coupled, approximately 6 Kb B. bigemina-DNA probe (BBDP), was used to indicate the presence of the parasite. Serum samples from 925 animals of all ages, were obtained within the three regions (I, II, III) of the state of Yucatan and tested by IFAT. In addition, whole blood samples drawn from 136 of the same animals of region II were analyzed using the BBDP. Positive IFAT (IFAT+) reactions were observed in 531 sera for a 57% overall prevalence. Regional values were: I = 157+ (56%), II = 266+ (68%) and III 108+ (42%). Only 32 (23%) of the blood samples tested with BBDP showed distinctive hybridization signal, in contrast with 100 (73%) IFAT+ animals. The response distribution for IFAT vs. BBDP was: +/+ 23, +/- 77, -/+ 9 and -/- 27 respectively. It was found that the analytical sensitivity of BBDP appears to be low for its utilization in widespread epidemiological surveys. It was considered, however, that the colorimetric probe might be useful to safely detect transmission prone carriers, since it is able to detect parasitemias as low as 0.001%.